Neer Type-II Distal Clavicle Fractures

Abstract

Background: Neer type-II distal clavicle fractures are unstable and are generally appropriately managed with operative fixation. Fixation options include locking plates, hook plates, and suture button devices. No consensus on optimal technique exists. Methods: A decision tree model was created describing fixation of Neer type-II fractures using hook plates, locking plates, or suture buttons. Outcomes included uneventful healing, symptomatic implant removal, deep infection requiring debridement, and nonunion requiring revision. Weighted averages derived from a systematic review were used for probabilities. Cost-effectiveness was evaluated by calculating incremental cost-effectiveness ratios (ICERs). The ICER is defined as the ratio of the difference in cost and difference in effectiveness of each strategy, and is measured in cost per quality-adjusted life year (QALY). The model was evaluated using thresholds of $50,000/QALY and $100,000/QALY. Sensitivity analysis was performed on all outcome probabilities for each fixation strategy to assess cost-effectiveness across a range of values. Results: Forty-three papers met final inclusion criteria. Using suture buttons as the reference case in the health-care cost model, suture button repair was dominant (both less expensive and clinically superior). Hook plates cost substantially more ($5,360.52) compared with suture buttons and locking plates ($3,713.50 and $4,007.44, respectively). Suture buttons and locking plates yielded similar clinical outcomes (0.92 and 0.91 QALY, respectively). Suture button dominance persisted in the societal perspective model. Sensitivity analysis on outcome probabilities showed that locking plates became the most cost-effective strategy if the revision rate after their use was lowered to 2.2%, from the overall average in the sources of >19%. No other changes in outcome probabilities for any of the 3 techniques allowed suture buttons to be surpassed as the most cost-effective. Conclusions: The cost-effectiveness of suture buttons is driven by low revision rates and high uneventful healing rates. Similar QALY values for locking plate and suture button fixation were observed, which is consistent with existing literature that has failed to identify either as the clinically superior technique. Cost-effectiveness should fit prominently into the decision-making rubric for these injuries. Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fixation of distal clavicle fractures with coracoclavicular instability: a comparative biomechanical study in human cadavers

“…From a health economic view, suture button devices have shown better cost-effectiveness than hook or locking plate fixation for Neer type II distal clavicle fractures owing to both lesser implant costs and better effectiveness with a high uneventful healing rate of 96%. 8 The implant costs of the cow-hitch fixation amount to 212 USD (1 Dog Bone Button at 174 USD, 2 FiberWire No. 5 sutures at 38 USD), thus being even less expensive than the DB technique with about 850 USD (1 Dog Bone kit at 669 USD, 1 additional FiberTape suture at 189 USD).…”

“…Overall fixation strength and cyclic loading properties of a cow-hitch suture repair with distal only button fixation were compared with those of a well-studied suture tape double-button fixation (Arthrex Dog Bone) in a human cadaver model. 5 , 7 , 8 , 11 , 23 , 32 …”

A Novel and Open Classification Emphasizing on Osteoligamentous Complex for Distal Clavicle Fractures

“…Also, the current methods cannot classify all types of DCFs, 14,15 with low repeatability, making the diagnostic highly subjective. At last, X‐ray cannot directly show the CC ligament injury, and in practice, there is often confusion in the classification, which leads to differences in guiding surgical treatment 16 …”

“…At last, X-ray cannot directly show the CC ligament injury, and in practice, there is often confusion in the classification, which leads to differences in guiding surgical treatment. 16 This study aimed to (i) develop a novel and open classification system describing a large range of DCFs based on osteoligamentous injury patterns; and (ii) apply this novel system in our clinical practices for treatment planning and investigate its reliability.…”

Comparing the locking screw direction of three locking plates for lateral clavicle fractures: a simulation study

“…There are numerous surgical options for fixing lateral clavicle fractures. The lateral clavicle locking plate osteosynthesis that does not overlap the acromioclavicular joint (ACJ), hook plate osteosynthesis that spans the ACJ, and reconstruction of the coracoclavicular ligament [4][5][6]. Locking plate fixation is usually used in patients with a relatively large lateral fragment because a small fragment cannot take enough screws to achieve robust fixation.…”