Open Reduction and Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures

Robinson, C. M.; Goudie, Ewan B.; Murray, Iain R.; Jenkins, Paul J.; Ahktar, M A; Read, E O; Foster, Caroline; Clark, Kenneth A.; Brooksbank, Andrew; Arthur, A; Crowther, Mark; Packham, Iain; Chesser, Tim

doi:10.2106/jbjs.l.00307

Cited by 371 publications

(336 citation statements)

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“…Fourth, the QuickDASH score is not specifically designed for patients with a displaced midshaft clavicle fracture. Nevertheless, it often is used as one of the tools to measure function [1,4,[18][19][20]. Fifth, because patients experience and recall symptoms differently, we know this study could be susceptible to recall bias.…”

Section: Discussionmentioning

confidence: 98%

High Irritation and Removal Rates After Plate or Nail Fixation in Patients With Displaced Midshaft Clavicle Fractures

Hulsmans

Heijl

Houwert³

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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Background Studies comparing plate with intramedullary nail fixation of displaced midshaft clavicle fractures show faster recovery in the plate group and implant-related complications in both groups after short-term followup (6 or 12 months). Knowledge of disability, complications, and removal rates beyond the first postoperative year will help surgeons in making a decision regarding optimal implant choice. However, comparative studies with followup beyond the first year or two are scarce. Questions/purposes We asked: (1) Does plate fixation or intramedullary nail fixation for displaced midshaft clavicle fractures result in less disability? (2) Which type of fixation, plate or intramedullary, is more frequently associated with implant-related irritation and implant removal? (3) Is plate or intramedullary fixation associated with postoperative complications beyond the first postoperative year?Methods Between January 2011 and August 2012, patients with displaced midshaft clavicle fractures were enrolled and randomized to plate or intramedullary nail fixation. A total of 58 patients with plate and 62 patients with intramedullary nails initially were enrolled. Minimum followup was 30 months (mean, 39 months; range, 30-51 months). Two patients (3%) with plate fixation and two patients (3%) with intramedullary nails were lost to followup. The QuickDASH was obtained at final followup and compared between patients who had plate fixation and those who had intramedullary nail fixation. Postoperative complications measured include infection, implant-related irritation, implant failure, nonunion, and refracture after implant removal. Indications for implant removal included implant-related irritation, implant failure, nonunion, patient's wish, or surgeon's preference. Results Between patients with plate versus intramedullary nail fixation, there were no differences in QuickDASH The institution of one or more of the authors (FJW, RMH, EJV) has received, during the study period, funding from the AO Foundation ((Dübendorf, Switzerland). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that his institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. Conclusions After a mean followup of 39 months, disability scores were excellent. Major complications did not occur after the 1-year followup. A frequent and bothersome problem after both surgical treatments is implant-related irritation, resulting in high rates of implant removal, after 1 year. Future research could focus on analyzing risk factors for implant irritation or removal. Level of Evidence Level II, therapeutic study.

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Section: Discussionmentioning

confidence: 98%

High Irritation and Removal Rates After Plate or Nail Fixation in Patients With Displaced Midshaft Clavicle Fractures

Hulsmans

Heijl

Houwert³

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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“…Collation of literature on clavicle fractures suggests that the expected nonunion rate is 8.6%. This percentage was derived from the reported healing rate in 12 separate publications [59][60][61][62][63][64][65][66][67][68][69][70] spanning the period from 2004 to 2013 and including 3168 patients treated with a range of conservative and operative methods. Both samples are large, and the nonunion rate in our database again differs by less than a percentage point from the literature values.…”

Section: Discussionmentioning

confidence: 99%

Epidemiology of Fracture Nonunion in 18 Human Bones

et al. 2016

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IMPORTANCE Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors.OBJECTIVE To test a hypothesis that fracture characteristics and patient-related risk factors assessable by the clinician at patient presentation can indicate the probability of fracture nonunion.DESIGN, SETTING, AND PARTICIPANTS An inception cohort study in a large payer database of patients with fracture in the United States was conducted using patient-level health claims for medical and drug expenses compiled for approximately 90.1 million patients in calendar year 2011. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology codes; comorbidities as per International Classification of Diseases, Ninth Revision codes; and drug prescriptions as per National Drug Code Directory codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion. Data analysis was performed from January 1, 2011, to December 31, 2012, EXPOSURES Continuous enrollment in the database was required for 12 months after fracture to allow sufficient time to capture a nonunion diagnosis. RESULTSThe final analysis of 309 330 fractures in 18 bones included 178 952 women (57.9%); mean (SD) age was 44.48 (13.68) years. The nonunion rate was 4.9%. Elevated nonunion risk was associated with severe fracture (eg, open fracture, multiple fractures), high body mass index, smoking, and alcoholism. Women experienced more fractures, but men were more prone to nonunion. The nonunion rate also varied with fracture location: scaphoid, tibia plus fibula, and femur were most likely to be nonunion. The ORs for nonunion fractures were significantly increased for risk factors, including number of fractures (OR, 2.65; 95% CI, 2.34-2.99), use of nonsteroidal anti-inflammatory drugs plus opioids (OR, 1.84; 95% CI, 1.73-1.95), operative treatment (OR, 1.78; 95% CI, 1.69-1.86), open fracture (OR, 1.66; 95% CI, 1.55-1.77), anticoagulant use (OR, 1.58; 95% CI, 1.51-1.66), osteoarthritis with rheumatoid arthritis (OR, 1.58; 95% CI, 1.38-1.82), anticonvulsant use with benzodiazepines (OR, 1.49; 95% CI, 1.36-1.62), opioid use (OR, 1.43; 95% CI, 1.34-1.52), diabetes (OR, 1.40; 95% CI, 1.21-1.61), high-energy injury (OR, 1.38; 95% CI, 1.27-1.49), anticonvulsant use (OR, 1.37; 95% CI, 1.31-1.43), osteoporosis (OR, 1.24; 95% CI, 1.14-1.34), male gender (OR, 1.21; 95% CI, 1.16-1.25), insulin use (OR, 1.21; 95% CI, 1.10-1.31), smoking (OR, 1.20; 95% CI, 1.14-1.26), benzodiazepine use (OR, 1.20; 95% CI, 1.10-1.31), obesity (OR, 1.19; 95% CI, 1.12-1.25), antibiotic use (OR, 1.17; 95% CI, 1.13-1.21), osteoporosis medication use (OR, 1.17; 95% CI, 1.08-1.26), vitamin D deficiency (OR, 1.14; 95% CI, 1.05-1.22), diuretic use (OR, 1.13; 95% CI, 1.07-1.18), and renal insufficiency (OR, 1.11; 95% CI, 1.04-1.17) (multivariate P < .001 for all).C...

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“…2,[5][6][7][8] However, more recent studies have suggested that operative treatment results in increased patient satisfaction, superior functional capabilities, and decreased rates of nonunion and malunion when compared with nonoperative management. [9][10][11][12] Operative management of midshaft clavicle fractures may involve the use of various techniques for reduction and fixation. 12 Currently, open reductioneinternal fixation is considered the gold-standard treatment because of the immediate rigid stability provided by the fixation device.…”

Section: Introductionmentioning

confidence: 99%

“…[18][19][20] In addition, autologous iliac crest bone graft (ICBG) has proved to augment osteosynthesis during fixation of nonunion fractures through the release of osteogenic factors. 2,11,[13][14][15][16][17] However, studies have associated ICBG harvesting with significant donor-site morbidity, including neurologic and vascular injury, incisional hernia, donor-site fracture, and deep infection. [21][22][23][24] Therefore, the purpose of this article was to describe a surgical technique developed to reduce donor-site morbidity and improve functional outcomes after open reductioneinternal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.…”

Section: Introductionmentioning

confidence: 99%

“…12 Currently, open reductioneinternal fixation is considered the gold-standard treatment because of the immediate rigid stability provided by the fixation device. 2,11,[13][14][15][16][17] Internal fixation of midshaft clavicle fractures may involve the use of contoured plates or intramedullary nails. [18][19][20] In addition, autologous iliac crest bone graft (ICBG) has proved to augment osteosynthesis during fixation of nonunion fractures through the release of osteogenic factors.…”

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confidence: 99%

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Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation

Slette

Mikula

Turnbull

et al. 2016

Arthroscopy Techniques

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Abstract:Currently, open reductioneinternal 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 reduce donor-site morbidity and improve functional and objective outcomes after open reductioneinternal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.T he clavicle is one of the most commonly fractured bones, representing 5% to 15% of all fractures. 1 Fractures of the midshaft account for approximately 80% of all clavicular fractures because the junction between the lateral and middle third is the thinnest portion of the bone and lacks muscular and ligamentous reinforcement. 2,3 Historically, fractures of the middle third of the clavicle were managed nonoperatively because closed treatment was believed to yield a low nonunion rate and minimal functional impairment. 4 In addition, clavicular malunion, which occurs to some degree in approximately two-thirds of midshaft clavicle fractures, was previously described as being solely a radiographic anomaly with no clinical significance. 2,5-8 However, more recent studies have suggested that operative treatment results in increased patient satisfaction, superior functional capabilities, and decreased rates of nonunion and malunion when compared with nonoperative management. [9][10][11][12] Operative management of midshaft clavicle fractures may involve the use of various techniques for reduction and fixation. 12 Currently, open reductioneinternal fixation is considered the gold-standard treatment because of the immediate rigid stability provided by the fixation device. 2,11,[13][14][15][16][17] Internal fixation of midshaft clavicle fractures may involve the use of contoured plates or intramedullary nails. [18][19][20] In addition, autologous iliac crest bone graft (ICBG) has proved to augment osteosynthesis during fixation of nonunion fractures through the release of osteogenic factors. 2,11,[13][14][15][16][17] However, studies have associated ICBG harvesting with significant donor-site morbidity, including neurologic and vascular injury, incisional hernia, donor-site fracture, and deep infection. [21][22][23][24] Therefore, the purpose of this article was to describe a surgical technique developed to reduce donor-site morbidity and improve functional outcomes after open reductioneinternal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.

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Open Reduction and Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures

Cited by 371 publications

References 18 publications

High Irritation and Removal Rates After Plate or Nail Fixation in Patients With Displaced Midshaft Clavicle Fractures

High Irritation and Removal Rates After Plate or Nail Fixation in Patients With Displaced Midshaft Clavicle Fractures

Epidemiology of Fracture Nonunion in 18 Human Bones

Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation

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