Functional outcomes and complications of plate fixation for midshaft clavicle fractures by type and location: a systematic review and meta-analysis

Background

Various plate types are used in the surgical treatment of displaced midshaft clavicle fractures. These plates can be positioned in different locations on the clavicle, although no studies to date have elucidated optimal plate type and location of fixation. This systematic review compares the functional outcomes and complications in the management of displaced midshaft clavicle fractures using plate fixation by stratifying by both plate type and location.

Methods

A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted to identify all papers reporting functional outcomes, union rates, and/or complications using plates for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until March 2022. A meta-analysis was conducted for functional outcomes and type of complication, stratified by plate type (locking, compression, or reconstruction) and location (superior or anteroinferior). Pooled estimates of functional outcome scores and incidence of complications were calculated using a random effects model. Risk of bias and quality were assessed using the risk of bias version 2 and ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tools. The confidence in estimates were rated and described according to the recommendations of the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) working group.

Results

Forty-five studies were included in the systematic review and 43 were included in the meta-analysis. Depending on plate type and location, pooled Constant-Murley Scores ranged from 89.23 to 93.48 at 12 months. Nonunion rates were 3% (95% confidence interval [CI] 1-6) for superior locking plates (GRADE Low). Rates of any complication (nonunion, hardware failure, hardware irritation, wound dehiscence, keloid, superficial infection, deep infection, delayed union, malunion, and/or persistent pain) by plate type and location ranged from 3% to 17% (GRADE Very Low to Moderate). Superior compression plates had the highest incidence of any complications (17% [95% CI 5-44], GRADE Very Low), while anterior inferior compression plates had the lowest incidence of any complication (3% [95% CI 0-15], GRADE Very Low). Hardware irritation was the most reported individual complication for superior locking plates and superior compression plates, 11% (95% CI 7-17, GRADE Low) and 11% (95% CI 3-33, GRADE Very Low), respectively.

Conclusion

Although most studies were of low quality, studies reporting functional outcomes generally showed good functional results and similar incidence of any complication regardless of plate type and location. There is no evidence of a plate and location combination to optimize patient functional outcomes or complications. We were unable to reliably evaluate union rates or individual complications for most plate types stratified by location.

Clavipectoral fascia plane block in midshaft clavicle fractures: A cadaveric study

STUDY OBJECTIVE

The objective of this anatomical study was to investigate the distribution of a solution administered using the Clavipectoral Fascia Plane Block (CPB) technique in a series of cadaveric models with midshaft clavicular fractures. The study aimed to address the knowledge gap regarding the impact of clavicular fractures on the distribution pattern of the CPB-administered solution.

DESIGN

Observational cadaveric study.

SETTING

The research was conducted in the laboratory setting of the University of Barcelona, adhering to the institution's ethical guidelines and standards.

PATIENTS

Five unembalmed human cadavers were used, generating ten clavicle samples.

INTERVENTIONS

A postmortem fracture was induced in the middle third of the clavicle using a blunt-edged hammer, simulating a midshaft clavicular fracture.

MEASUREMENTS

Anatomical dissection was performed in three layers: the superficial muscle plane, deep muscle plane, and clavicular periosteum plane. Dye staining with methylene blue was utilized to assess the distribution pattern.

MAIN RESULTS

In the superficial muscular plane, methylene blue was observed in the deltoid (100%), pectoralis major (100%), sternocleidomastoid (SCM) (70%), and trapezius muscles (100%). Conversely, the deep muscular plane, including the subclavius muscle, pectoralis minor, and Clavipectoral Fascia (CPF), exhibited no staining. At the clavicular periosteum plane, methylene blue distributed predominantly to the antero-superior region (57.3%), with a minimal impact on the postero-inferior area (6.5%).

CONCLUSIONS

The study reveals that the presence of a midshaft clavicular fracture does not significantly alter the diffusion pattern of the CPB-administered solution, maintaining a consistent distribution in both intact and fractured clavicle models.

Do multiple fractures affect risk of fixation failure after surgical treatment of midshaft clavicle fracture? A retrospective cohort study

BACKGROUND

Surgical treatment of midshaft clavicle fractures is associated with quick recovery and low risk of non-union. However, fixation failure may occur in case of severe comminution fractures. Moreover, clinical outcomes may be affected when clavicle fractures occur in combination with other injuries, particularly those involving the lower extremities, as the use of crutches or walkers may hinder the process of rehabilitation by adding strain on the acromioclavicular (AC) joint, resulting in possible fixation failure. This study aims to identify risk factors for fixation failure of midshaft clavicle fractures and elucidate the role of combined fractures in treatment outcomes.

METHODS

This study included patients diagnosed with midshaft clavicle fractures who underwent initial surgery between January 2012 and November 2021 at a designated regional trauma center hospital. Retrospective evaluation of fixation failure was carried out in 352 patients with midshaft clavicle fractures using standard clinical evaluation protocols and conventional radiographs. The prevalence of fixation failure and the effects of several demographic variables on the risk of fixation failure and non-union were examined. Multivariate logistic regression analysis was carried out to identify independent risk factors for fixation failure.

RESULTS

Fixation failure occurred in 40 patients (11.4%). Multivariate analysis identified comminution [odds ratio (OR) 3.532, p value = 0.003, 95% confidence interval (CI) 1.55-8.05)] and fewer number of screws (OR 0.223, p value = 0.022, 95% CI 0.06-0.80) as risk factors for fixation failure. Surgical techniques using wire cerclage reduced the chances of fixation failure in comminuted fractures (OR 0.63, p value = 0.033, 95% CI 0.05-0.80). Combined fractures that required rehabilitation using walkers or crutches increased the risk of non-union (OR 19.043, p value = 0.032, 95% CI 1.28-282.46).

CONCLUSIONS

Additional fixation of comminuted fractures using cerclage can reduce the risk of treatment failure, while multiple fractures or rehabilitation for ambulation increases the risk of the same.

LEVEL OF EVIDENCE

III.

Long-term conservative treatment outcomes for midshaft clavicle fractures: a 10-to-30-year follow-up

BACKGROUND

Few reports exist on the long-term outcomes of midshaft clavicle fracture conservative treatments. Therefore, this study investigated the long-term outcome of this treatment in patients with midshaft clavicle fractures.

METHODS

Patients were treated conservatively for midshaft clavicle fractures with a figure-of-eight bandage between 10 and 30 years ago. Subsequently, a telephone survey was used to follow-up these patients, and 38 were successfully evaluated. The mean term after trauma was 17.0 years. Afterward, the American Shoulder and Elbow Surgeons Shoulder (ASES) score and Shoulder pain and disability index (SPADI) on the affected and unaffected sides were calculated based on the filled questionnaires. We defined patients whose ASES and SPADI on the affected side were worse than the unaffected side as the symptomatic group. Furthermore, plain radiographs measured proportional changes in clavicular length and displacement.

RESULTS

The ASES scores of the affected side were significantly lower than those of the unaffected side, and the SPADI of the affected side was significantly higher than that of the unaffected side. Furthermore, the symptomatic group's proportional changes in clavicular length and displacement were significantly larger than the asymptomatic group.

CONCLUSION

The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively. Moreover, several patients became symptomatic for fractures with a larger proportional change in clavicular length or displacement.

Minimally invasive plate osteosynthesis for displaced midshaft clavicle fractures: An indirect reduction using joystick technique

BACKGROUND

A minimally invasive plate osteosynthesis (MIPO) technique has become increasingly popular in long bone fracture fixation as it could eliminate postoperative complications. However, the most challenging aspect of employing the MIPO for midshaft clavicle fractures among general orthopedic surgeons is the technically demanding that indirect reduction is typically a closed maneuver.

METHODS

We present a consecutive series of patients with displaced midshaft clavicle fractures undergoing clavicular fixation using the MIPO technique between January 2017 and October 2019. The joystick technique was used to obtain anatomical reduction. Clinical outcomes were assessed using the Constant-Murley and the American shoulder and elbow surgeons shoulder scores.

RESULTS

Thirty patients with a mean age of 42.44 years were included. The functional shoulder scores showed no disabilities compared with those of a healthy population. No major complications requiring re-operation were noted, and all fractures were completely healed with an average time of 12.53 weeks.

CONCLUSION

This study demonstrated that facilitating the MIPO for midshaft clavicle fractures using simple operative devices and techniques was possible. The joystick technique with the use of an external fixator for temporary stabilization is a safe and effective method that can be added to achieve anatomical alignment with the fracture site unexposed. This technique could be performed either in a fresh fracture or a delayed case with failed conservative treatment.

Midshaft Clavicle Fractures: When Is Surgical Management Indicated and Which Fixation Method Should Be Used?

For displaced midshaft clavicle fractures, operative treatment either with open reduction and plate fixation or with intramedullary fixation has been shown to provide earlier return to work and sport, improved functional outcomes, greater patient-reported satisfaction with appearance, and significantly decreased incidence of nonunion and malunion when compared with conservative treatment. Operative intervention is not without risks associated with surgery. Shared decision-making with the patient and understanding patient goals allows surgeons to recommend a management option that the patient will be comfortable with and will follow to achieve a satisfactory outcome.

Operative stabilisation versus non-operative management of mid-shaft clavicle fractures

INTRODUCTION

Fractures of the mid-shaft clavicle are commonly encountered in clinical practice. These can be managed either by conservative method or operative by internal fixation. This study aims to compare the outcomes of conservative and operative management.

METHODS

Forty patients with displaced and comminuted mid-shaft clavicle fractures were included in the study, among which twenty-five patients were treated conservatively and 15 patients underwent surgery and were followed up for a period of 1 year. Time taken for union, functional outcome, complications, and patient satisfaction were compared.

RESULTS

In the non-operative group, 28% of the fractures took less than twelve weeks to unite, whereas in the operative group 60% of them took less than 12 weeks to unite. At the end of 1 year, there was no statistical difference in mean UCLA (University of California and Los Angeles) score and the mean DASH score of the non-operative group and operative group. There were more complications in the operative group. Re-operative rate in the operative group was 40%. Patient satisfaction was 80% in the non-operative group, whereas 48% of patients were satisfied in the operative group.

CONCLUSION

Displaced and comminuted mid-shaft clavicle fractures treated conservatively have more advantages when compared to surgically treated fractures.

Risk factors for complications and reoperation following operative management of displaced midshaft clavicle fractures

BACKGROUND

Optimal management of a displaced midshaft clavicle fracture remains controversial. This study assessed demographic factors, fracture pattern, and surgical technique as potential predictors of surgical complications. Smoking, diabetes, obesity, polytrauma, high-energy mechanism, inpatient status, transverse or comminuted fractures, and single-plating technique were hypothesized to be associated with an increased risk of complications following clavicle fracture open reduction internal fixation (ORIF).

METHODS

Consecutive patients with minimum 12-week follow-up from the trauma and sports medicine divisions at a single tertiary institution who presented with a midshaft clavicle fracture and underwent ORIF between 2007 and 2020 were retrospectively identified. Patient demographics, fracture pattern, plating technique, and postoperative complications were recorded. Postoperative complications were classified into major (reoperation) and minor (no reoperation) complications. Chi-squared statistics, Fisher's exact test, analysis of variance, Kruskal-Wallis test, and multivariate logistic regression modeling were utilized with a significance level set to P < .05.

RESULTS

One hundred ninety-eight patients (average = 39.5 ± 14.6 years) were identified with an average follow-up of 9.1 ± 10.7 months. The cohort consisted of 155 males (78.3%), 62 smokers (31.3%), and 12 diabetics (6.1%). Injury characteristics revealed 80 transverse fractures (40.4%), 87 oblique fractures (43.9%), and 31 Z-type fractures (15.7%). Seventy-nine patients (39.9%) underwent superior plating, 72 (36.4%) underwent anterior plating, and 47 (23.7%) underwent dual plating. Overall, postoperative complications occurred in 47 patients (23.7%), 29 minor (14.6%) and 18 major (9.1%). Major complications requiring reoperation were symptomatic hardware, nonunion, deep infection, wound dehiscence, and broken hardware. Minor complications consisted of sensory deficit or paresthesia beyond peri-incisional numbness, superficial infections, postoperative pain and/or stiffness, and delayed union. Smoking status (P = .008), obesity (P = .009), and transverse or Z-type fractures (P = .002) were significant prognostic factors for overall complication risk. Only manual labor was predictive of minor complications (P = .019). Transverse or Z-type fractures and single plating were predictive of major complications (P = .004 and P = .008, respectively). No reoperations occurred in patients who underwent dual plating. Smokers (P = .027) with transverse/Z-type fractures (P = .022) were at the highest risk of reoperation with single plating.

CONCLUSION

The overall rate of complications following ORIF of displaced midshaft clavicle fracture was 27.3%, with 9.1% requiring reoperation. Given relatively high complication rates, in instances when nonoperative vs. operative management is equivocal, nonoperative management should be strongly considered in obese patients, smokers, and patients who present with transverse or Z-type fracture. If operative management is indicated, use of dual plating may decrease reoperation rates.

Comparison of 3 treatment methods for midshaft clavicle fractures: A systematic review and network meta-analysis of randomized clinical trials

BACKGROUND

Our study aims to evaluate the fracture nonunion rate and the functional score of plate and screw fixation, intramedullary nailing and non-surgical treatment in midshaft clavicle fractures patients using a network meta-analysis of data from clinical randomized controlled trials.

MATERIAL/METHODS

The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA).

RESULTS

24 randomized controlled trials involving 2161 participants were included. The studies were published between 2007 and 2019. A total of 3 treatment methods-plate and screw fixation, intramedullary nailing and non-surgical treatment- were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the constant score, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. In terms of the DASH index, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. In terms of the nonunion rate, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment.

CONCLUSION

Non-surgical treatment has a high rate of nonunion for clavicular fractures with obvious displacement and notable comminution. Surgical treatment reduces the nonunion rate leads to better functional scores at long-term follow-up, although there may be no significant clinical differences. The fracture nonunion rate of plate screw fixation group and intramedullary nail group was low and the functional prognosis was similar. More RCTs focused on clavicular fractures are needed to further substantiate this conclusion.

Dual mini-fragment plate fixation of midshaft clavicle fractures is biomechanically equivalent to anatomic pre-contoured plating

OBJECTIVES

To biomechanically compare the stiffness of midshaft synthetic clavicle osteotomies fixed with either superior anatomic pre-contoured locking plates, anterior anatomic pre-contoured locking plates, or short-segment dual orthogonal mini-plate fixation.

DESIGN AND SETTING

Controlled laboratory study. Specimens Twenty-one synthetic pre-osteotomized clavicles were separated into three groups: superior plating, anterior plating, or dual-plating. Each clavicle was sequentially tested in non-destructive cycles of axial compression, three-point bending, and torsion. Load and displacement were recorded. Stiffness was calculated.

RESULTS

No statistically significant differences were found between construct stiffness during axial compression, three-point bending, or torsional testing. One superior plated clavicle suffered catastrophic failure during axial compression. One dual mini-fragment plated clavicle suffered catastrophic failure during torsion.

CONCLUSIONS

Orthogonal dual mini-fragment fixation of transverse clavicle fractures is biomechanically similar to superior and anterior pre-contoured anatomic locking plate fixation. No statistically significant differences in construct stiffness were found in axial compression, three-point bending, or torsion testing. Further clinical research is required to determine the long-term stability of dual mini-fragment plate fixation.

LEVEL OF EVIDENCE

IV.

Skin Tenting in Displaced Midshaft Clavicle Fractures

BACKGROUND

The objectives of this study were to (1) identify factors associated with skin tenting in displaced midshaft clavicle fractures and (2) analyze individual surgeon variation in this diagnosis.

METHODS

A retrospective cohort study was performed at two Level I trauma centers of 396 patients with displaced midshaft clavicle fractures treated by 47 surgeons with open reduction internal fixation from January 2010 to March 2019. Our main outcome measure was skin tenting, as diagnosed by the treating surgeon and used as an indication for surgical treatment.

RESULTS

Skin tenting was diagnosed by the treating surgeon in 34 out of 396 patients (9%) with displaced midshaft clavicle fractures. Multivariable logistic regression analyses showed that lower BMI (P=0.002) and fracture shortening (P=0.03) were independently associated with skin tenting in displaced midshaft clavicle fractures. There was wide variation among surgeons in the rate of diagnosis of skin tenting, ranging from 0% to 41% prevalence of skin tenting depending on the treating surgeon (P<0.0001).

CONCLUSION

Although lower BMI and greater fracture shortening were associated with skin tenting, the diagnosis is subjective. We found wide variation in the diagnosis of skin tenting, even among surgeons within a single metropolitan area.

Can 3D-printing avoid discomfort-related implant removal in midshaft clavicle fractures? A four-year follow-up

INTRODUCTION

Due to the variation in shape and curvature of the clavicle, plates often have to be adjusted during surgery to acquire a good fit. Poorly fitted plates can cause discomfort, eventually requiring implant removal. 3D-printed replicas of the fractured clavicle can assist in planning of the surgical approach, plate selection and, if necessary, adjustment of the plate prior to surgery. We hypothesized this method of preoperative preparation would reduce implant-related discomfort resulting in a reduced reoperation rate MATERIALS AND METHODS: In a prospective cohort study, perioperative plate handling and clavicle fixation were timed and follow-up data were collected from participants undergoing operative treatment for a midshaft clavicle fracture. The control group (n = 7) received conventional surgery with standard precontoured plates. For the intervention group (n = 7), 3D-printed replicas of the fractured clavicle and a mirrored version of the healthy contralateral clavicle were available prior to surgery for planning of the surgical approach, and for plate selection and contouring. Primary outcome was reoperation rate due to implant-related discomfort. Secondary outcomes were complications and time differences in the different surgical phases (reduction, fixation and overall operation time) RESULTS: More participants in the control group had the plate removed due to discomfort compared to the intervention group (5/7 vs. 0/6; P = 0.012). One participant was excluded from the intervention group due to a postoperative complication; an infection occurred at the implant site. No relevant time difference in surgical plate handling was found between both groups.

CONCLUSIONS

Preoperative preparation using 3D-printed replicas of the clavicle fracture may reduce implant removal caused by plated-related discomfort. No relevant effect on surgery time was found.

TRIAL REGISTRATION

Registered with 'toetsingonline.nl', trial number NL51269.075/14, 17-02-2015.

Clinical and Radiological Outcomes after Various Treatments of Midshaft Clavicle Fractures in Adolescents

Backgroud

Controversy exists about the optimal treatment of midshaft clavicle fractures in the presence of significant displacement, comminution, or shortening of the fracture in adolescents. The purpose of this study was to compare the clinical and radiological outcomes of 4 different treatments for midshaft clavicle fractures in adolescents: conservative treatment with a figure-of-8 (FO8) brace, open reduction and internal fixation with a plate (OPL), minimally invasive plate osteosynthesis (MIPO), and intramedullary nail fixation with a threaded Steinmann pin (TSP).

Methods

A total of 94 teenagers with midshaft clavicle fractures were divided into the FO8, OPL, MIPO, and TSP groups (n = 24, 33, 16, and 21, respectively). We analyzed clinical and radiological outcomes and complications in each group and compared the results among the groups.

Results

All groups showed satisfactory clinical and radiological outcomes, but each group showed different results for the assessment items. The Constant-Murley scores were higher in the operated groups than in the FO8 group. Recovery of joint motion was faster in the operated groups. The TSP group had the highest cosmetic satisfaction with respect to the satisfaction score and measured scar length. Fracture union was achieved in all patients. At the final follow-up, the bone length was closer to normal in the OPL and TSP groups than in the FO8 and MIPO groups, and angulation was less in the OPL and TSP groups than in the MIPO and FO8 groups. The TSP and MIPO groups obtained faster bone healing than the OPL and FO8 groups. In the operated groups, 9 patients had metal-induced irritating symptoms; 1, supraclavicular nerve injury symptoms; and 4, refractures after plate removal.

Conclusions

The nonoperatively treated group had no iatrogenic complications. The operated groups complained of various disadvantages induced by surgery; however, these groups achieved faster functional recovery and slightly better radiological and functional results than the nonoperative group.

Biomechanical comparison between solid and cannulated intramedullary devices for midshaft clavicle fixation

Background

A method of closed reduction and internal fixation with cannulated screws was proposed as a surgical treatment of midshaft clavicle fractures. However, there are no mechanical studies about the cannulated screw used in the fixation of midshaft clavicle fracture. We conducted this study to compare the construct bending stiffness of a fixation midshaft clavicle fracture with a Knowles pin, cannulated screw and reconstruction plate. In addition, purchase lengths of both intramedullary devices were measured.

Methods

After transverse osteotomy over the midpoint for fracture simulation, eighteen synthetic clavicles were assigned to 3 groups and fixed with reconstruction plate, Knowles pin or cannulated screw. Purchase length was defined as the engaged length of the intramedullary portion of the two intramedullary devices Stiffness, yield load and maximum load of the cantilever bending test were calculated of each tested synthetic bones.

Results

The Knowles pin group had a significantly longer average intramedullary purchase length compared with that of the cannulated screw group. The construct stiffness in the reconstruction plate group (5.6 ± 0.9 N/mm) was higher than that of the intramedullary devices; the Knowles pin group (3.1 ± 0.6 N/mm) provided a greater construct stiffness than did the cannulated screw group (1.7 ± 0.4 N/mm) (p = 0.007). The cannulated screw group had the lowest yield and maximum load compared with the reconstruction plate and Knowles pin groups. Both the reconstruction plate and Knowles pin failed at the implant-bone interface. However, the cannulated screw group failed at the osteotomy site with broken implants.

Conclusion

This study suggests that fixation of midshaft clavicle fractures with cannulated screws may lead to early failure due to inadequate mechanical strength. Ideal intramedullary clavicle devices should supply adequate intramedullary purchase lengths and mechanical strength.

Bioabsorbable plating in the treatment of pediatric clavicle fractures: A biomechanical and clinical analysis

BACKGROUND

Classic implants for operative intervention of mid-shaft clavicle fractures in adolescents can become symptomatic, requiring removal. This study compares 1) biomechanical properties and 2) clinical outcomes in adolescents of mid-shaft clavicle fracture fixation with bioabsorbable versus metal implants.

METHODS

Six synthetic clavicles with mid-shaft fractures underwent bioabsorbable plating. A testing frame applied 10 non-destructive torsion and 10 axial compression cycles, followed by cantilever bending to failure. Stiffness was calculated; maximum failure load and failure mode were recorded. Results were compared to previous data for locked metal constructs. Retrospective review of surgically treated clavicle fractures over three years included functional and radiographic outcomes.

FINDINGS

Bioabsorbable plates had lower torsional stiffness (P < 0.001) and maximum cantilever load (P < 0.0001) than locked metal plates. There was no significant difference in compression stiffness (P = 0.2) or cantilever bending stiffness (P = 0.4). Primary failure of metal plates was screw pull-out compared to plate bending in bioabsorbable constructs. Seven patients with bioabsorbable implants were included. All patients with bioabsorbable constructs achieved radiographic union, but 71% lost reduction. Despite fracture angulation, all achieved normal shoulder function after one year determined by QuickDASH evaluation. None required a second surgery.

INTERPRETATION

Bioabsorbable implants had lower torsional stiffness and cantilever failure load, but comparable compression stiffness to metal implants. Bioabsorbable implants failed via gradual bending versus the catastrophic failure seen in metal implants. The clinical review allows understanding of the sequelae of this lower failure load of bioabsorbable plates where their use allowed in fracture displacement, yet achievement of ultimate radiographic union and acceptable functional outcomes.

Plating for midshaft clavicular fractures: The impact on quality of life and functional outcome

INTRODUCTION

Several studies report on functional outcome after operative treatment for midshaft clavicular fractures. According to the published data not much is known about the quality of life after operative treatment. The purpose of this study is to investigate long term patient reported quality of life (QoL) and functional outcome after plating for midshaft clavicular fractures.

METHODS

Patients between 16 and 65 years of age, with a midshaft clavicular fracture which were treated with plate fixation between 2006 and 2014, were included. Information was extracted from hospital records and all patients were asked to participate in an online survey. Primary outcome was QoL (SF-36 and EQ-5D-5L). Secondary outcomes were complications, reoperation rate, patient- and cosmetic satisfaction, pain, and functional outcome (DASH).

RESULTS

In a retrospective cohort design, 164 patients were included, 101 completed the online survey. Patients reported a good QoL and functional outcome. The mean physical- and mental SF36 score were 53.9±7.3 and 52.3±9.9 (0-100), the EQ-5D-5L score was 0.88±0.17 (-0.59 to 1.0) and the average DASH was 8.45±14.0 (0-100). Furthermore, there was a strong correlation between the functional outcome and QoL (p<0,001). Seventeen patients developed at least one complication (10%) and seventy-seven patients got a reoperation, with isolated implant removal as the leading cause of reoperation (80,5%).

CONCLUSION

Patients which received operative treatment for a midshaft clavicle fracture have an excellent QoL, and a good functional outcome. Furthermore, there is a strong relationship between functional outcome and the QoL.

Plate fixation or intramedullary fixation for midshaft clavicle fractures: a systematic review and meta-analysis of randomized controlled trials and observational studies

BACKGROUND

The last decade has shown a shift toward operative treatment of a subset of midshaft clavicle fractures. However, it is unclear whether there are differences between plate fixation and intramedullary fixation regarding complications and functional outcome. The aim of this systematic review and meta-analysis was to compare plate fixation and intramedullary fixation for midshaft clavicle fractures.

METHODS

The Medline, Embase, and Cochrane databases were searched for both randomized controlled trials and observational studies. The methodologic quality of all included studies was assessed using the Methodological Index for Non-Randomized Studies.

RESULTS

Twenty studies were included. Ten of the 20 included studies used a fracture classification. Seven of these studies reported exclusion of patients with comminuted fractures. No difference in the total re-intervention rate was found (odds ratio [OR], 1.21; 95% confidence interval [CI], 0.71 to 2.04). Major re-interventions occurred more often after plate fixation (OR, 1.88; 95% CI, 1.02 to 3.46). The mean implant removal rates were 38% after plate fixation and 73% after intramedullary fixation. Re-fracture after implant removal occurred more often after plate fixation (OR, 3.42; 95% CI, 1.12 to 10.42). The Constant-Murley scores showed no differences at both short term (mean difference, -1.18; 95% CI, -13.41 to 11.05) and long term (mean difference, 0.15; 95% CI, -1.57 to 1.87). No differences were observed regarding nonunion (OR, 1.50; 95% CI, 0.82 to 2.75). The rate of infections showed no differences when outlier studies were excluded (OR, 1.54; 95% CI, 0.88 to 2.69).

CONCLUSION

Major re-intervention and re-fracture after implant removal occurred more frequently after plate fixation of non-comminuted, displaced midshaft clavicle fractures. No differences in terms of function and nonunion between plate fixation and intramedullary fixation were observed.

Titanium Elastic Nail versus plate fixation of displaced midshaft clavicle fractures: A retrospective comparison study

This study has two purposes: (1) to compare the clinical results between the Titanium Elastic Nail (TEN) and plate fixation of the displaced midshaft clavicle fracture; and (2) to demonstrate the relationship between length shortening and functional outcome after TEN fixation, especially in the comminuted fracture pattern. A retrospective, case-controlled study was conducted and 55 patients were included in our study: 25 in the TEN fixation group (TEN group) and 30 in the plate fixation group (plate group). All patients were classified into four subgroups: simple fracture in the TEN group (ST; n = 13), simple fracture in the plate group (SP; n = 15), comminuted fracture in the TEN group (CT; n = 12), and comminuted fracture in the plate group (CP; n = 15). Wound size was significantly smaller in the TEN group (p < 0.001). The injured clavicular length after fracture healing was significantly shorter in the TEN group (p = 0.036). There was no significant difference in the mean Constant and DASH scores. Injured clavicle shortening was significantly larger in the CT subgroup (p = 0.018). However, there was no statistically significant difference in Constant score and DASH score while comparing the CT subgroup to other subgroups. Although TEN fixation may lead to a higher degree of length shortening after bony union especially in cases of comminuted fracture pattern, no statistically significant difference was observed in objective functional results as compared to other subgroups. Therefore, TEN can be used to fix a displaced midshaft clavicle fracture even in cases of comminuted fracture pattern, which overall is an effective and less surgically invasive procedure.