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

Abstract

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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“…However, in recent years, some literature reports have shown that there are some major drawbacks in autologous transplantation, such as pain in the donor region, hematoma in the bone graft area, nerve damage and paresthesia, and even infections. In addition, limited bone mass, prolonged operation time and extra bleeding during surgery add to the disadvantages of autologous bone grafting 36,37. Furthermore, the bone graft may also have risks of position changing and bone absorbing, sclerosis and necrosis, still resulting in bone defects.…”

Arthroscopic-Assisted Bone Graft Harvest From the Proximal Humerus for Distal Third Clavicle Fracture Nonunion

“…As they note, their technique is limited by the quantity of local bone graft available and the fact that drilling may cause heat-induced osteonecrosis and influence the quality of the bone graft as well. 17 Our technique features several advantages compared with the previously described literature ( Table 3 ). We endorse a standard shoulder arthroscopy set-up with minimal modifications in the prepping and draping to incorporate the clavicle.…”

“…14 Although the use of free vascularized bone grafting has been reported for the treatment of clavicle fracture nonunion, this is predominantly reserved for larger defects in the revision setting. 15,16 Slette et al 17 recently described a technique using local bone graft harvest for ORIF of the clavicle. They recommend careful collection of the bony remnants during ORIF of the clavicle from the drill holes and the drill flutes prior to placement of the screws.…”

“…Slette et al. 17 recently described a technique using local bone graft harvest for ORIF of the clavicle. They recommend careful collection of the bony remnants during ORIF of the clavicle from the drill holes and the drill flutes prior to placement of the screws.…”