Biomechanical Evaluation of Different Plate Configurations for Midshaft Clavicle Fracture Fixation

Abstract

Background: Dual-plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating with small-fragment clavicle plates for biomechanical noninferiority and to determine if an optimal plate configuration could be identified using a cadaveric model.Methods: Twenty-four cadaveric clavicles were randomized to 1 of 6 groups, stratified by computed tomography-based bone mineral content (BMC): precontoured superior or anterior fixation using a single 3.5-mm Locking Compression Plate (LCP), and 4 different dual-plating constructs utilizing 2.4-mm and 2.7-mm Adaptation plates or LCPs. An inferior butterfly fracture was created. Axial, torsional, and bending (anterior and superior surface loading) stiffnesses were determined through nondestructive cyclic testing, followed by a load-to-failure test in 3-point superior surface bending.Results: For axial stiffness, the 2 dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either Adaptation or LCP) were significantly stiffer than the other 4 constructs (p = 0.021 and p = 0.034). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared with the 3.5-mm superior plate (p = 0.043). No significant differences were found in torsional stiffness or load to failure between the different constructs.Conclusions: Dual plating using mini-fragment plates is biomechanically superior for the fixation of midshaft clavicle fractures when compared with a single, superior, 3.5-mm plate and has biomechanical properties similar to those of a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual-plating constructs were compared with each other.Clinical Relevance: This study validates the use of dual plating for midshaft clavicle fractures. Clavicle fractures are common injuries, with the middle one-third of the clavicle accounting for two-thirds of all fractures 1-3 . Nonoperative management remains the predominant treatment modality for these fractures. However, the treatment paradigm has changed over the past decade following numerous high-quality randomized controlled studies indicating that nonoperative outcomes are not as favorable as once believed [4][5][6][7] . Nonetheless, the recommended indications for surgical treatment are still conflicting. Most of the debate surrounds secondary operative procedures, as the number of patients who require a second operation (8.0% to 20.8%) is considerable 6,8 . The most common indication for a secondary surgical procedure is implant irritation 8 .Although various fixation methods of midshaft clavicle fractures have been described, plate fixation remains the most establi...

Clinical Outcomes of Double Mini-Plating Compared with a Single Superior Plating in Midshaft Clavicular Fractures: A Randomized Clinical Trial Study

“…In contrast to past studies, recent investigations showed surgical fixation leads to lower rate of non-union and better functional outcomes in patients with displaced midshaft clavicular fractures. [ 7 ] However, thin soft tissue coverage of this area makes it susceptible to surgical-related wound complications and device prominence. Single superior plating of the clavicle bone is an accepted method of surgical fixation for displaced midshaft clavicular fractures.…”

“…[ 6 ] Newly, some biomechanical studies showed the advantages of midshaft clavicular fracture fixation with double mini-plates. [ 7 ] Ziegler et al . reported similar biomechanical outcomes of double-plating construct in comparison with superior or anteroinferior single plating.…”

“…On the other hand, there are different combinations of 3.5, 2.7, and 2.4 mm plates in the literature. [ 7 ] Therefore, selecting the proper device for dual-plating is still unclear. Choosing the optimal surgical method provides better functional outcomes and union rate with the minimum surgical-related problems such as wound complications, bleeding, device prominence, and cosmetic issues.…”

Screw Stress Distribution in a Clavicle Fracture with Plate Fixation: A Finite Element Analysis

“…Some authors had previously studied clavicle fixation with FE analysis and found that when screw holes were positioned close to the fracture site, there was a significant increase in stress on the plate and clavicle [64,65]. This indicates that screw positioning close to the fracture can have a significant effect on the stress pattern in the plate fixation system [66]. These changes in stress patterns can potentially affect the healing process, long-term fracture stability, rehabilitation program, and clinical outcomes [67].…”

Management of Displaced Midshaft Clavicle Fractures in Pediatrics and Adolescents: Operative vs Nonoperative Treatment

“…However, dual plate constructs had similar torsional and bending stiffness to anterior single plate constructs. 46 Though we can extrapolate some data from adult populations, none of these studies were specifically performed in the adolescent or pediatric population and differences between plating position in this population remain an open question. Despite increased biomechanical stability, there are no studies in a pediatric population to suggest that dual plate constructs improve clinical outcomes.…”