Long-term functional outcome assessment of plate fixation and autogenous bone grafting for clavicular non-union

doi:10.1016/S0020-1383(03)00239-0

Injury

Volume 35, Issue 6, June 2004, Pages 575-579

https://doi.org/10.1016/S0020-1383(03)00239-0 Get rights and content

Abstract

Introduction: The aim of our study was to assess the long-term functional and radiological outcome of clavicular non-union in patients treated with open reduction and bone grafting. A total of 24 non-unions treated between 1994 and 2001 were analysed using chart and radiological review and assessed with the American Academy of Orthopaedic Surgeons (AAOS) DASH questionnaire. Results: There were 13 males and 10 females with a mean age of 37.95 (range 21–65) years. One patient had bilateral injuries. The average time from injury to operation was 10.3 (range 4–29) months and the average follow-up post-operatively was 42.1 (range 6–75) months. All patients were treated using a dynamic compression or reconstruction plate with autogenous bone grafting. Twenty-two of the 24 non-unions eventually healed. DASH assessment indicated a higher level of disability in the treated group than found in the normal population. This only proved significant in the sub-population of patients with associated co-morbidities. Conclusion: We conclude that the long-term outcome results of this procedure indicate it to be a well-tolerated and successful operation in treating the disability and pain associated with clavicular non-union. Most patients return to a daily level of function close to the general population. Patients with associated co-morbidities should have these treated pre-operatively for best results.

Introduction

Clavicular fractures are estimated to constitute between 5 and 10% of adult skeletal trauma presenting to the fracture clinic.⁴ Despite this, progression to non-union is rare with an incidence between 0.1 and 1%.¹⁵ When this complication occurs, the residual problems incurred by the patient are often significant, including not only pain, but also disability and often a considerable upper limb functional deficit.12., 15., 17. Optimal treatment for post-traumatic clavicular non-union is often debated and previous studies have described plate,8., 9., 12., 13., 14., 18. intramedullary,¹ and external fixation.¹⁶

Open reduction and internal fixation with a compression plate and bone grafting is currently the most accepted technique,2., 5., 7., 17. producing consistently good outcomes in a number of series.5., 7., 14. Information regarding long-term extremity function is rarely reported, as most studies identify bone healing and resolution of pain as end points of treatment. Therefore the objective of this study was to study long-term functional outcome after treatment for clavicular non-union with a reliable and validated assessment tool. Subsequently, possible causes for poor outcomes in these patients were analysed.

Section snippets

Patients and methods

We retrospectively analysed chart, radiological and operative data on all patients operated upon for clavicular non-union over a 7-year period. Thirty non-unions were identified in 29 patients, with one patient having bilateral injuries. All patients identified had been symptomatic for 16 weeks prior to the diagnosis of non-union. Open reduction and internal fixation was performed by a number of experienced consultants, with reconstruction plates being used in seven patients and dynamic

Results

There were no immediate post-operative complications, however two patients developed long-term complications including one patient with a reflex sympathetic dystrophy and one patient with a deep local infection, which necessitated plate removal.

Discussion

The clavicle has a pivotal role in the biomechanical function of the pectoral girdle and also the function of the upper limb.¹¹ Given this importance, much interest has been focused on the optimal method of treatment for patients with clavicular non-union. The underlying theme in many papers is to analyse the pre-disposing causes for non-union¹⁷ and early symptomatic or radiological outcome.5., 7., 8., 9., 10., 12., 13., 14. Our report is unique in that it analyses the long-term functional

Conclusions

We conclude that open reduction and internal fixation with bone grafting gives good long-term functional and radiological results in clavicular non-union with most patients returning to a functional level close to the general population. However, patients known to have co-morbid conditions, compromised post-operative function and these co-morbidities should, if possible, be concomitantly treated.

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Cited by (31)

Computer-assisted planning vs. conventional surgery for the correction of symptomatic mid-shaft clavicular nonunion and malunion
2023, JSES International
The aim of this study was to compare the clinical and radiographic outcomes of treatment of symptomatic mal- and/or nonunion of midshaft clavicle fractures using radiographically based free-hand open reduction and internal fixation (ORIF) or computer-assisted 3D-planned, personalized corrective osteotomies performed using patient-specific instrumentation (PSI) and ORIF. The hypotheses were that (1) patients treated with computer-assisted planning and PSI would have a better clinical outcome, and (2) computer-assisted surgical planning would achieve a more accurate restoration of anatomy compared to the free-hand technique.
Between 1998 and 2020, 13 patients underwent PSI, and 34 patients underwent free-hand ORIF and/or corrective osteotomy. After application of exclusion criteria, 12/13 and 11/34 patients were included in the study. The clinical examination included measurement of the active range of motion and assessment of the absolute and relative Constant–Murley Scores and the subjective shoulder value. Subjective satisfaction with the cosmetic result was assessed on a Likert scale from 0 to 100 (subjective aesthetic value). 11/13 and 6/11 patients underwent postoperative computed tomography evaluation of both clavicles. Computed tomography scans were segmented to generate 3D surface models. After projection onto the mirrored contralateral side, displacement analysis was performed. Finally, bony union was documented. The average follow-up time was 43 months in the PSI and 50 months in the free-hand cohort.
The clinical outcomes of both groups did not differ significantly. Median subjective shoulder value was 97.5% (70; 100) in the PSI group vs. 90% (0; 100) in the free-hand group; subjective aesthetic value was 86.4% (±10.7) vs. 75% (±18.7); aCS was 82.3 (±10.3) points vs. 74.9 (±26) points; and rCS was 86.7 (±11.3) points vs. 81.9 (±28.1) points. In the free-hand group, 2/11 patients had a postoperative neurological complication. In the PSI cohort, the 3D angle deviation was significantly smaller (PSI/planned vs. free-hand/contralateral: 10.8° (3.1; 23.8) vs. 17.4° (11.6; 42.4); P = .020)). There was also a trend toward a smaller 3D shift, which was not statistically significant (PSI/planned vs. free-hand/contralateral: 6 mm (3.4; 18.3) vs. 9.3 mm (5.1; 18.1); P = .342). There were no other significant differences. A bony union was achieved in all cases.
Surgical treatment of nonunion and malunions of the clavicle was associated with very good clinical results and a 100% union rate. This study, albeit in a relatively small cohort with a follow-up of 4 years, could not document any clinically relevant advantage of 3D planning and personalized operative templating over conventional radiographic planning and free-hand surgical fixation performed by experienced surgeons.
Arthroscopic-Assisted Bone Graft Harvest From the Proximal Humerus for Distal Third Clavicle Fracture Nonunion
2020, Arthroscopy Techniques
Clavicle fracture nonunion can lead to persistent pain and loss of shoulder function. Distal clavicle fractures have the greatest risk of nonunion and are often treated surgically. Bone grafting plays a vital role in the treatment of distal clavicle nonunion. Although multiple options for bone graft exist, the iliac crest has long been considered the gold standard for harvest. Despite its extensive use, multiple complications have been associated with iliac crest bone graft harvest. We advocate a surgical technique for arthroscopic bone graft harvest from the proximal humerus with open reduction and internal fixation of an ipsilateral distal clavicle nonunion.
Corrective osteotomy in symptomatic clavicular malunion using computer-assisted 3-D planning and patient-specific surgical guides
2018, Journal of Orthopaedics
Citation Excerpt :
Moreover there is often an esthetic component with shortening and “ptosis” of the shoulder. Although an osteotomy that simply corrects the length can improve some of these symptoms, it is important to note that apparently some degree of residual shoulder dysfunction is expected postoperatively if not performed correctly.8,9 Although all publications specifically addressing clavicle osteotomies did report improvement, none of these patients had a normal shoulder outcome score.
Surgical correction of a symptomatic clavicular malunion requires simultaneous adjustment of the translation as well as the rotation in multiple planes. We describe a corrective osteotomy for a clavicle malunion using 3-D computer assisted preoperative-planning combined with patient-specific surgical guides, along with the benefits and disadvantages of this approach. This method enabled quantifying the malunion by comparing the malunited bone with the normal contralateral clavicle as a template. The postoperative results were encouraging with symmetrical shoulder anatomy and functional improvement. Therefore, we recommend this technique in patients with a symptomatic clavicle malunion, as it allows successful correction of the deformity.
Late recurrent peripheral upper limb ischemia after non-union of a clavicle fracture
2015, Injury
Citation Excerpt :
Compression plating and autologous bone grafting is the gold standard for the treatment of symptomatic clavicle non-union. Stable and rigid fixation is desirable in order to reach bone healing and early functional recovery [25–27]. Biomechanical studies suggest that superior plating compared with anterior plating can give greater stability despite the detriment of a higher incidence of hardware-related symptoms and risk of damages to neurovascular structures.
A 74-year-old woman was referred to our hospital due to recurrent episodes of upper limb ischemia. Her past medical history included a clavicle non-union developed after a clavicle midshaft fracture that had occurred 30 years previously. After a long asymptomatic period, she started showing symptoms of chronic ischemia to the left arm that were misdiagnosed. Thoracic outlet syndrome (TOS) is a rare but possible complication of mal-union and non-union of clavicle fractures; symptoms related to arterial involvement (ATOS) amount to less than 1% of all existing forms of thoracic outlet syndrome. In case of clavicle non-union, local instability plays a key role in determining the initial injury to the vessels and the recurrence of symptoms. Restoration of local bone stability and anatomy, obtained by compression plating and autologous bone grafting, combined with an appropriate vascular surgery, is essential to achieve a clinical resolution of symptoms and to avoid the recurrence of symptomatology as seen in the herein case.
Management of clavicle nonunion and malunion
2013, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
Moreover, clavicle nonunion is frequently hypertrophic, and compression plating is capable of providing a rigid and length-stable construct in nearly all situations. Available literature suggests that bony union can be reliably achieved after surgical management of clavicle nonunion or malunions.14,42,43 Both superior and anteroinferior plating techniques have resulted in satisfactory union rates in the setting of clavicle nonunion.
Clavicle fractures are common injuries of the shoulder girdle and occasionally result in nonunion or symptomatic malunion. When present, these chronic injuries can result in considerable shoulder dysfunction. A number of surgical techniques have been described for the management of these injuries. Current literature suggests that supplemental bone grafting may not be necessary in all cases but should be considered in the setting of atrophic nonunion. However, optimal treatment is controversial, as discussed in the literature. This article highlights the current treatment options based on the existing literature and describes our preferred techniques.
We carried out a comprehensive review of the PubMed and Medline databases using multiple keywords (eg, clavicle fracture, clavicle nonunion, and clavicle malunion) to identify the relevant literature regarding this topic. Reference lists of the relevant articles were reviewed for additional important articles.
Nonunion and malunion of the clavicle remain challenging problems. Reliable bony union and improved shoulder function can be expected with thoughtful surgical planning, appropriate implant choice, and meticulous surgical technique.
Surgical management of uncomplicated midshaft clavicle fractures: A comparison between titanium elastic nails and small reconstruction plates
2012, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
Although the first 4 patients in the TEN group were not completely satisfied because of implant-related complications, with greater surgical experience and adjustment of TEN positioning, the latter patients were all satisfied. Although reconstruction plates provide primary rigid fixation, time to subjective pain relief is dependent on repair of a large surgical wound and periosteal dissection.5,16 In addition to the preclusion of shoulder exercises by the 3- to 6-week requirement for arm sling protection after SRP fixation, restoration of shoulder joint motion might be delayed in consideration of potential loosening of screws in osteoporotic bone.2
This study compared titanium elastic nail (TEN) fixation with plate fixation in patients with uncomplicated midshaft clavicle fractures.
The records of 57 patients with midshaft clavicular fractures that were operated on within 2 weeks after injury at Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan, were retrospectively analyzed. Each patient received either TENs (n = 25) or fixation with a 3.5-mm reconstruction plate (n = 32) depending on the preference of the operating surgeon. Operative parameters, postoperative pain and function scores, complications, and fracture union time were determined.
There was no difference in the fracture pattern distribution between the 2 groups, and all operations were performed without complications. Operation time, wound size, blood loss, length of hospitalization, and subjective time to pain relief were less for the TEN group than for the 3.5-mm reconstruction plate fixation group (P < .001 for all). Patients in the TEN group showed a greater range of shoulder motion and higher Constant scores than those in the plate fixation group up to 18 weeks after surgery (P < .001 for all). Fewer patients in the TEN group, 4 (16%), requested removal of the implant, as compared with 12 (37.5%) in the plate group.
Fixation of uncomplicated midshaft clavicle fractures with TENs provides adequate fixation and faster relief of pain and return to normal function of the affected shoulder than fixation with 3.5-mm reconstruction plates.

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Long-term functional outcome assessment of plate fixation and autogenous bone grafting for clavicular non-union

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusions

Injury

Non-union of fractures of the mid-shaft of the clavicle

J. Bone Joint Surg.

Clavicular non-union: 31/32 healed after plate fixation and bone grafting

Acta Orthop. Scand.

Normative data for the SF-36® version II from the Oxford Healthy Lifestyle Survey III

J. Public Health Med.

Operative treatment for delayed and non-union of midshaft clavicular fractures

J. Trauma

Clavicular fracture non-union surgical outcomes and complications

Injury

Open reduction and internal fixation with bone grafting of clavicular non-union

J. Trauma

Treatment of post-traumatic clavicular pseudo-arthrosis

Acta Orthop. Scand.

Normative data for the SF-36^® version II from the Oxford Healthy Lifestyle Survey III