Congenital pseudoarthrosis of the clavicle: Should we reconsider timing and fixation method?

Abstract

Background: Congenital pseudoarthrosis of the clavicle (CPC) is rare and may require treatment, usually because of an unacceptable appearance or occasionally because of pain in an adolescent patient. Spontaneous union is unknown, and consequently any desired union requires open reduction and bone grafting. Many authors recommend performing the operation at the age of 3-5 years and using different fixation methods. We present our experience with three cases and literature review in an attempt to further elucidate the appropriate timing of the procedure and the fixation method. Methods: This was a retrospective review of three cases presenting with pseudoarthrosis of the clavicle. All cases were treated by curettage of the pseudoarthrosis, with the void filled using full-thickness ileac crest autologous bone graft and bridging plate-one compression and two anatomical, at different ages. We performed a literature review with emphasis on timing of the procedure, fixation method and complications. Results: All patients healed with good callus formation. One patient (5-year-old female treated using a compression plate) experienced overlying skin irritation and underwent removal of the plate. There were no restriction of movement, pain or any other complaint on the final follow-up. We did not find any difference in the operating complexity at different ages, but when a compression plate was used, it had to be removed later due to bulging of the plate. Discussion: No clinical difference was observed between earlier and late operation. Therefore, we suggest performing a curettage of the pseudoarthrosis, gapping the void using autologous bone graft, and using an anatomical bridging plate.

Use of a Free Vascularized Medial Femoral Condyle Flap for Revision Surgery in a Pediatric Patient with Congenital Pseudarthrosis of the Clavicle

“…Shalom reported on a 45-year-old asymptomatic patient with CPC and recommended conservative management if there are no symptoms [11]. On the other hand, even if there are no symptoms, some authors recommend early surgical treatment because the operation is easier [13].…”

“…On the other hand, even if there are no symptoms, some authors recommend early surgical treatment because the operation is easier before the gap enlarges with age [ 3 , 6 , 12 ]. However, Giwnewer et al found that no clinical references were observed between patients who underwent earlier and late-stage operations [ 13 ].…”

Surgical Management of Congenital Pseudoarthrosis of the Clavicle: A Review of Current Concepts

“…Surgical intervention involves the resection and excision of pseudoarthrosis, bone grafting, and internal fixation. Bone grafting most often involves the use of autograft tissue from the iliac crest [3,6,[12][13][14]16,21,23,[25][26][27][28]. Other grafts have included allograft, local corticocancellous graft from debrided pseudarthrosis fragments, and a mix of autograft and allograft [3,13].…”

“…The two primary methods of internal fixation involve the use of reconstruction plates [4,12,13,16,[21][22][23][24][25][26]28,30] or K-wires [3,4,6,14,23,27,28]. One alternative method for internal fixation used by Kim et al for patients younger than 18 months was nonabsorbable suture [13].…”

“…According to a review of studies up to 2010, operative treatment was most successful in children aged two to four years [ 9 ]. More recent reports suggest five to seven years for surgical intervention [ 21 , 22 ], while most of the literature recommends three to five years [ 9 , 14 , 23 ], indicating that resection of the focus of the pseudoarthrosis occurs at this time [ 9 ]. In the largest study to date comparing the timing of surgical intervention by Kim et al, rates of returning to the operating room were greater in patients who underwent surgery at >18 months (median age 6 years), but rates of nonunion were more common in the patients who underwent surgery at <18 months (median age 8 months) [ 13 ].…”