Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation.
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ABSTRACT:
SUBMITTER: Slette EL
PROVIDER: S-EPMC5021388 | biostudies-literature | 2016 Jun
REPOSITORIES: biostudies-literature
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Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation.
Slette Erik L EL Mikula Jacob D JD Turnbull Travis Lee TL Hackett Thomas R TR
Arthroscopy techniques 20160530 3
Currently, open reduction-internal fixation using contoured plates or intramedullary nails is considered the standard operative treatment for midshaft clavicle fractures because of the immediate rigid stability provided by the fixation device. In addition, autologous iliac crest bone graft has proved to augment osteosynthesis during internal fixation of nonunion fractures through the release of osteogenic factors. The purpose of this article is to describe a surgical technique developed to reduc ...[more]
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Project description:BACKGROUND:Midshaft clavicle fractures are one of the most familiar fractures. And, dual small plate fixation has been reported as can minimize hardware-related complications. However, the biomechanical properties of the dual small plate fixation have not yet been thoroughly evaluated. Here, we report the results of a finite element analysis of the biomechanical properties of midshaft clavicle fractures treated with dual small plating and superior and anteroinferior single plate fixation. METHODS:A three-dimensional (3D) finite element model of the midshaft clavicle fractures was created, whose 4-mm transverse fracture gap, having an angle < 30 degree and devoid of overlapping triangles, was simulated between the fractured segments of the middle-shaft of the clavicle. The equivalent von Mises stress and displacement of the model was used as the output measures for analysis. RESULTS:No significant differences were found between dual plating, superior or anteroinferior single plating in cantilever bending, axial compression, and axial torsion. Dual plating with a smaller plate-screw construct is biomechanically eligible to compare with superior and anteroinferior single plate fixation using larger plate-screw constructs. CONCLUSIONS:This study demonstrated that larger plate-screw constructs for the treatment of simple are placed clavicular fractures; however, weight-bearing and exorbitant shoulder activity should be avoided after the operation. Therefore, dual plating may provide a viable option for fixing midshaft clavicle fractures and, thus, may be preferred for patients who need early activity.
| S-EPMC7161212 | biostudies-literature
Project description:To assess the clinical and anatomical causes of cutaneous paresthesia after internal fixation of clavicle fractures.This study included 135 patients who underwent internal fixation of clavicle fractures from May 2013 to June 2016 at the First and Second Affiliated Hospital of Guangxi Medical University. The incidence of postoperative supraclavicular nerve injury, the duration of numbness, and improvements after plate removal were retrospectively analyzed. Seven human cadaver specimens were subsequently dissected to analyze the supraclavicular nerve and its relationship to numbness.Of the 135 patients who underwent internal fixation of clavicle fractures, 26 (19.3%) experienced postoperative cutaneous paresthesia, with 22 (16.3%) and 4 (2.8%) experiencing numbness and pain, respectively. The most intense numbness occurred during the first operative month. Of the 22 patients with numbness, 1 (4.5%), 1 (4.5%), and 20 (90.1%) patients reported mild, moderate, and severe numbness, respectively. Two patients described increased awareness of numbness when in contact with clothes, 2 were psychologically affected by numbness, and 20 (90.1%) reported reduced severity of numbness over time. At the last follow-up, numbness was found to persist in 2 (1.5%) patients. None of the patients was bothered by numbness. Cadaver dissection showed that the supraclavicular nerve emerged from the 1/2 posterior edge of the cervical sternocleidomastoid muscle and subsequently divided into 3 branches, with the lateral branch 2.26?±?1.17?cm from the lateral margin of the acromion, the middle branch near the mid-clavicle, and the medial branch 2.03?±?0.85?cm from the sternal lateral margin.Cutaneous paresthesia is common following internal fixation of the clavicle. Anatomic analysis showed that the nerve could be easily injured during clavicle operation. Numbness improved in most patients, but persisted for up to 2 years and was even permanent in a few. Most patients considered numbness as an insignificant factor in their daily lives.
| S-EPMC6203588 | biostudies-literature
Project description:BackgroundsThere is no consensus concerning whether surgery or non-surgical treatment is preferred for displaced midshaft clavicle fracture. We performed a meta-analysis of randomized controlled trials (RCTs) to compare healing effects and cosmetic results between surgery and non-surgery.MethodsWe retrieved RCTs regarding open reduction and plate fixation (ORPF) and non-surgical method for the treatment of displaced midshaft clavicle fracture published before June 2018 from PubMed, EMBASE and Cochrane Library. The difference between the two treatments was comparatively discussed in aspects of nonunion, malunion, functional outcome, cosmetic results, and complications.ResultsNine RCTs were included. The results showed that ORPF is advantageous over the non-surgical treatment in terms of nonunion rate (RR, 0.11[95%CI, 0.06-0.23]), malunion rate (RR, 0.16[95%CI, 0.08-0.35]), appearance dissatisfaction rate (RR, 0.35[95%CI 0.23-0.55]), and shoulder appearance defect rate (RR, 0.06[95%CI, 0.02-0.17]). The non-surgical treatment showed lower rate of complication (RR, 1.60[95%CI, 1.02-2.53]) and no significant differences were found between the 2 treatment groups with respect to functional outcome (disabilities of the arm, shoulder and hand (DASH) questionnaire score) (MD, -4.17[95%CI, -9.35 to 1.01]).ConclusionsThis meta-analysis updated previous results. The current findings suggested that ORPF yielded better efficacy than conservation treatment for displaced midshaft clavicle fracture from perspectives of fracture healing and appearance.
| S-EPMC6531279 | biostudies-literature
Project description:Background:Surgical management of completely displaced midshaft fractures of the clavicle is becoming more frequent, although long-term follow-up with Level-I evidence is scarce. Plate fixation (PF) of comminuted fractures provides faster functional recovery than elastic stable intramedullary nailing (ESIN). The 12-month follow-up of this randomized controlled trial, published previously, found no clinical differences at that time on the group level, but subtle differences on the subgroup level indicated that the results after closed ESIN were better than those after open ESIN. The primary aim of the study reported here was to compare the long-term clinical outcomes and sequelae after open reduction with those after closed reduction and to help surgeons develop a treatment strategy of either PF or ESIN for selected patients. Methods:At a median follow-up of 66 months (range, 49 to 89 months), the 123 patients in the original study were invited to an online secure survey. We used the survey results to compare the PF and ESIN treatment arms and to perform predetermined subgroup analyses of closed compared with open ESIN in relation to Disabilities of the Arm, Shoulder and Hand (DASH) score, pain assessment, and implant removal. Results:The questionnaire was completed by 114 (93%) of the 123 patients. There were no differences between the 2 treatment arms with regard to the DASH score (ESIN, 3.1 ± 7.0 and PF, 3.7 ± 7.5; p = 0.9). The 27 patients who had been treated with closed ESIN had a significantly superior DASH score compared with the 27 patients who had been treated with open ESIN (closed, 0.7 ± 1.4 and open, 5.2 ± 8.9; p = 0.015) and compared with the patients who had been treated with PF (closed ESIN, 0.7 ± 1.4 and PF, 3.9 ± 7.5; p = 0.002). Patients who had been treated with closed ESIN also reported fewer sequelae than patients who had been treated with open ESIN or PF. Conclusions:The results of this study, combined with those of our prior 1-year follow-up of the same patients, indicate that it seems to be advantageous to perform closed ESIN. The long-term results after PF were similar to those after open ESIN, but PF resulted in faster functional recovery and fewer patients needing to have the implant removed. Therefore, if open reduction is necessary for a comminuted fracture, it seems that the advantages of the minimally invasive ESIN procedure are lost, and the surgeon should consider conversion to PF. Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
| S-EPMC6400504 | biostudies-literature
Project description:BackgroundAn alternative to the current gold standard in operative treatment of displaced midshaft clavicle fractures (DMCF) using plate osteosynthesis, is internal fixation by means of intramedullary fixation devices. These devices differ considerably in their specifications and characteristics and an evaluation of their clinical results is warranted. The aim of this systematic review is to generate an overview of functional outcomes and complications in the management of DMCF per available intramedullary device.MethodsA systematic review was conducted to identify all papers reporting functional outcomes, union rates and/or complications using an intramedullary fixation device for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until February 2020. Meta-analysis was conducted based on functional outcomes and type of complication per type of intramedullary fixation device. Pooled estimates of functional outcomes scores and incidence of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates were rated and described according to the recommendations of the GRADE working group.ResultsSixty-seven studies were included in this systematic review. The majority of studies report on the use of Titanium Elastic Nails (TEN). At 12?months follow up the Titanium Elastic Nail and Sonoma CRx report an average Constant-Murley score of 94.4 (95%CI 93-95) and 94.0 (95%CI 92-95) respectively (GRADE High). The most common reported complications after intramedullary fixation are implant-related and implant-specific. For the TEN, hardware irritation and protrusion, telescoping or migration, with a reported pooled incidence 20% (95%CI 14-26) and 12% (95%CI 8-18), are most common (GRADE Moderate). For the Rockwood/Hagie Pin, hardware irritation is identified as the most common complication with 22% (95%CI 13-35) (GRADE Low). The most common complication for the Sonoma CRx was cosmetic dissatisfaction in 6% (95%CI 2-17) of cases (GRADE Very low).ConclusionAlthough most studies were of low quality, good functional results and union rates irrespective of the type of device are found. However, there are clear device-related and device-specific complications for each. The results of this systematic review and meta-analysis can help guide surgeons in choosing the appropriate operative strategy, implant and informing their patient.Level of evidenceIV.
| S-EPMC7310279 | biostudies-literature
Project description:Introduction:The hypothesis of this study was that patient selection for midshaft clavicle fracture (open reduction internal fixation with plate versus conservative) would give better functional outcome than random treatment allocation. Methods:We performed a systematic literature search for primary studies providing functional score and non-union rate after conservative or surgical management of midshaft clavicle fractures. Six randomized controlled trial and 19 non-randomized controlled trial studies encompassing a total of 1348 patients were included. Results:Patients treated with surgical management were found to have statistically superior Constant scores in non-randomized controlled trials than in randomized controlled trials (94.76?±?6.4 versus 92.49?±?6.2; p?<?0.0001). For conservative treatment, randomized controlled trials were found to have significantly better functional outcome. The prevalence of non-union (6.1%) did not show significant statistical difference between non-randomized controlled trial and randomized controlled trial studies. The functional outcome after surgical management was significantly higher than after conservative management in both randomized controlled trial and non-randomized controlled trial groups. The non-union rate after surgery (1.1% for both non-randomized controlled trial and randomized controlled trial) was significantly lower than following conservative treatment (9.9% non-randomized controlled trial versus 15.1% randomized controlled trial). Discussion:This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture. Our results also confirm that plate fixation provides better functional outcome and lower non-union rate.
| S-EPMC6348584 | biostudies-literature
Project description:The two commonly performed surgical techniques used to repair displaced midshaft clavicle fractures are plate fixation or intramedullary nailing; however, despite recent evidence, the optimal method to treat such fractures remains a continued topic of debate. A meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate long term function, complications, and operative duration in adult patients receiving intramedullary nailing in comparison to plating. Seven RCTs and three quasi-randomized trials were included. No significant difference was found in long-term function between the two groups (MD: -0.66, 95% CI: -2.03 to 0.71, I(2)?=?62%, p?=?0.34). Patients who received plating had a 2.19 times increased risk of treatment failure, but this failed to reach significance (95% CI: 0.93 to 5.15, I(2)?=?0%, p?=?0.07). The risk of non-operative complications was 2.11 times higher in patients who received plating and this reached statistical significance (95% CI: 1.38 to 3.23, I(2)?=?53%, p?=?0.0006). Finally, plating significantly prolonged operative duration by 20.16?minutes (95% CI: 16.87 to 23.44, I(2)?=?56%, p?<?0.00001). Our results suggest that intramedullary nailing and plating provide equivalent long-term functional outcomes; however, plating may lead to a higher risk of treatment failure and non-operative complications.
| S-EPMC5071841 | biostudies-other
Project description:OBJECTIVES:To determine if level 1 evidence from a landmark trial changed practice patterns for treatment of patients with displaced midshaft clavicle fractures. DESIGN:Retrospective cohort study. SETTING:Two level 1 trauma centres. PARTICIPANTS:Displaced midshaft clavicle fractures. RESULTS:686 patients met inclusion criteria. The pretrial cohort (n=108) was 68.5% male, with a mean age of 37.7 (±13.9) years. The post-trial cohort (n=578) was 76.1% male, with a mean age of 41.9 (±12.7) years. There was nearly a 10-fold increase in the patients treated with openreduction and internal fixation (ORIF) in the post-trial cohort (34.1%) compared with the pretrial cohort (3.7%) (p<0.001). Patients in the post-trial cohort were more likely to undergo ORIF if they were <40 years (OR=2.2; 95% CI 1.53 to 3.10), if their Injury Severity Score was >9 (OR=1.6; 95% CI 0.89 to 2.99) or if they were treated at a centre that participated in the Canadian Orthopaedic Trauma Society ( COTS ) trial (OR=5.2; 95% CI 3.31 to 8.21). CONCLUSIONS:This study demonstrated a significant shift towards more frequent ORIF for displaced midshaft clavicle fractures following the COTS trial. Quantifying changes in practice pattern following publication of level 1 evidence is important to further our understanding of the impact large randomised clinical trails are having on clinical practice.
| S-EPMC6731861 | biostudies-other
Project description:Background:The majority of clavicle fractures are midshaft injuries, although fractures of the distal or medial fragment also occur. The aim of this study was to review the current evidence on these injuries to help inform future treatment plans. Methods:We searched for studies comparing interventions for medial, midshaft, or distal clavicle fractures; however, we did not identify any comparative studies on medial fractures and performed a secondary search on this topic. We conducted Bayesian network meta-analyses, although this was not feasible with studies on medial fractures and we described their results qualitatively. Results:For midshaft fractures, we found statistically significant improvements in function and time to radiographic union with plating, an elastic stable intramedullary nail (ESIN), and the Sonoma CRx intramedullary nail over nonoperative treatments. Both plating and an ESIN also showed significantly lower risks of nonunion and malunion relative to nonoperative methods. For distal fractures, a locking plate (LP) with or without coracoclavicular (CC) suturing yielded significantly better outcomes over K-wires with or without tension bands, CC suturing alone, an LP with a CC screw, a hook plate, and a sling. For medial fractures, plating may result in more favorable functional and union-related outcomes, although implant irritation may occur. In addition, K-wires, tension bands, and a screw with sutures demonstrated success when plating was technically not feasible in a few cases, whereas treatment with a sling may result in reduced function and a higher risk of complications relative to surgery. Conclusion:This study can provide guidance on the management of medial, midshaft, and distal clavicle fractures. The current evidence suggests that plating, an ESIN, and a CRx intramedullary nail are all good options for midshaft fractures; an LP with or without CC suturing should be preferred for distal fractures; and plating is also acceptable for medial fractures, provided that the patient is deemed suitable for surgery and has the adequate bone stock and sufficiently sized medial fragment necessary to implant the device. Patient preferences for certain outcomes should be considered, which may result in different treatment recommendations.
| S-EPMC7256900 | biostudies-literature
Project description:Fractures of the clavicle present very common injuries with a peak of incidence in young active patients. Recently published randomized clinical trials demonstrated an improved functional outcome and a lower rate of nonunions in comparison to non-operative treatment. Anterior chest wall numbness due to injury of the supraclavicular nerve and postoperative pain constitute common surgery related complications in plate fixation of displaced clavicle fractures. We recently developed a technique for mini open plating (MOP) of the clavicle to reduce postoperative numbness and pain. The purpose of this study was to analyze the size of anterior chest wall numbness and the intensity of postoperative pain in MOP in comparison to conventional open plating (COP) of clavicle fractures.24 patients (mean age 38.2 ± 14.2 yrs.) with a displaced fracture of the clavicle (Orthopaedic Trauma Association B1.2-C1.2) surgically treated using a locking compression plate (LCP) were enrolled. 12 patients underwent MOP and another 12 patients COP. Anterior chest wall numbness was measured with a transparency grid on the second postoperative day and at the six months follow-up. Postoperative pain was evaluated using the Visual Analog Scale (VAS).Mean ratio of skin incision length to plate length was 0.61 ± 0.04 in the MOP group and 0.85 ± 0.06 in the COP group (p < 0.05). Mean ratio of the area of anterior chest wall numbness to plate length was postoperative 7.6 ± 5.9 (six months follow-up 4.7 ± 3.9) in the MOP group and 22.1 ± 19.1 (16.9 ± 14.1) in the COP group (p < 0.05). Mean VAS was 2.6 ± 1.4 points in the MOP group and 3.4 ± 1.6 points in the COP group (p = 0.20).In our study, MOP significantly reduced anterior chest wall numbness in comparison to a conventional open approach postoperative as well as at the six months follow-up. Postoperative pain tended to be lower in the MOP group, however this difference was not statistically significant.ClinicalTrials.gov NCT02247778 . Registered 21 September 2014.
| S-EPMC4447026 | biostudies-literature