Retrospective comparison of titanium elastic nail (TEN) and reconstruction plate repair of displaced midshaft clavicular fractures

doi:10.1016/j.jse.2011.03.007

Journal of Shoulder and Elbow Surgery

Volume 21, Issue 4, April 2012, Pages 495-501

https://doi.org/10.1016/j.jse.2011.03.007 Get rights and content

Background

Titanium elastic nails (TENs) are commonly used to repair displaced midshaft clavicular fractures. Although several clinical studies have shown that the use of TENs is more effective and less invasive than traditional plate fixation, high rates of complications associated with TENs have been reported. This retrospective study compared the use of TENs with reconstruction plates in the treatment of displaced midshaft clavicular fractures.

Materials and methods

From January 2005 to July 2007, 141 patients with displaced midshaft clavicular fractures were treated with TEN or plate fixation. At 6 and 24 months postoperatively, we evaluated the patients’ general health, operative complications, and functional recovery.

Results

The mean bone union time of TEN patients was 12.4 ± 3.4 weeks, whereas that in the plate group was 14.4 ± 3.7 weeks. The time of union was significantly shorter in the TEN group than that in the plate group. There was no significant difference between these 2 groups’ rates of complications such as nonunion or malunion. Shoulder function scores were significantly better in the TEN group than in the plate group at 6 months postoperatively. There was no significant difference at 24 months postoperatively. Patients were more satisfied with the cosmetic appearance and overall outcome after TEN repair than after plate fixation.

Conclusions

TEN fixation of displaced midshaft clavicular fractures allows for a faster functional recovery, higher patient satisfaction, and a more cosmetically satisfactory appearance than plate fixation. The complication rates of both TENs and reconstruction plates were similar.

Section snippets

Materials and methods

We selected a demographically balanced sample of 141 patients (84 in plate group and 57 in nail group) with displaced midshaft clavicular fractures, who were operatively treated at our hospital from January 2005 to July 2007. The inclusion criteria for this study were (1) type A or B unilateral displaced midshaft clavicular fractures according to the Orthopaedic Trauma Association classification and (2) patient age between 18 and 65 years. These fractures are equally amenable to treatment by

Results

There were 57 TEN patients and 84 plate fixation patients. The TEN group ranged in age from 20 to 59 years, with a mean of 34.3 years. The plate fixation group age range was from 19 to 63 years, with a mean of 36.5 years. There were no significant differences in the demographic data or fracture characteristics between the 2 groups (Table I). Specifically, there was no significant difference between the 2 groups with respect to age, gender, fracture type, and mechanism of injury.

The operation

Discussion

Midshaft clavicle fracture has traditionally been managed with conservative treatment, which has few complications and good functional results. Neer¹⁹ reported a nonunion rate of 0.1% in 2,235 patients in 1960. However, more recent results showed a much higher nonunion rate in adults and unsatisfactory functional outcomes.2, 6, 15, 14, 16, 21, 22, 31 ORIF has gradually been recognized as an effective treatment for displaced or shortened (>2 cm) midshaft clavicular fractures.6, 31

Plate fixation

Conclusion

This study showed that TEN fixation of displaced midshaft clavicular fractures allows for shorter surgical time, less blood loss, better cosmetic outcomes with smaller scars, better functional outcomes, and greater patient satisfaction than reconstruction plate fixation. Complications rates were both similar and acceptable.

Acknowledgments

We greatly appreciate Sharon Yu, PhD, Department of Physiology and Biophysics, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA, for her editing of the English in this paper.

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Evidence on treatment of clavicle fractures
2023, Injury
Depending on the severity of the injury and the involvement of the soft tissue envelope, clavicle fractures can be treated operatively or non-operatively. In the past, displaced fractures of the clavicle shaft in adults have been treated non-operatively. However, the rate of nonunion following non-operative treatment seems to be higher than previously reported. In addition, publications reporting better functional outcomes following operative treatment are increasing. In recent years this has led to a paradigm shift towards an increase of operative fracture treatment.
The aim of this review article was to summarize the currently available evidence on the treatment of clavicle fractures. Classifications, indications, and treatment options for different fracture patterns of the medial, midshaft, and lateral clavicles are presented and discussed.
Results of pre-contoured titanium anterior plating of midshaft clavicle fractures
2022, Journal of Shoulder and Elbow Surgery
Plating midshaft clavicle fractures anteriorly is gaining popularity because of low complication rates. Improvements in plate fixation constructs for midshaft clavicle fractures have unclear clinical significance. The purpose of this study was to present the early clinical and radiographic outcomes of pre-contoured titanium anterior plates for the treatment of midshaft clavicle fractures.
Skeletally mature patients who underwent plate fixation of a midshaft clavicular fracture from 2008 to 2015 using pre-contoured titanium anterior plates were included in this retrospective investigation. The primary outcome measures were union rate and hardware removal rate. The secondary outcome measures included reoperation for all causes and mechanical implant failure.
A total of 26 patients were included. Complete healing occurred in 96% of patients without further surgical intervention, and all patients achieved union. Medical complications occurred in 2 patients (7.7%), consisting of cellulitis (n = 1) and chronic pain (n = 1). In 1 patient (3.8%), delayed union occurred and the use of a bone stimulator was required postoperatively to achieve union. Finally, 2 patients (7.7%) had symptomatic implants that required removal.
In the acute fracture setting, the anterior plating system used in this study led to a high rate of union with decreased rates of implant irritation. Only 7.7% of patients required hardware removal for symptomatic hardware, as opposed to the estimated 20%-60% reported in the literature in patients with symptomatic superior clavicle plates.
Functional outcomes, union rate, and complications of the Anser Clavicle Pin at 1 year: a novel intramedullary device in managing midshaft clavicle fractures
2020, JSES International
Surgical management of displaced midshaft clavicle fractures in adults leads to better union rates, improved early functional outcomes, and increased patient satisfaction compared with nonoperative treatment. However, both intramedullary fixation and plate osteosynthesis are subject to a specific array of disadvantages and complications. The Anser Clavicle Pin is a novel intramedullary device designed to address these disadvantages and complications. The aim of this study was to evaluate the union rate, functional outcomes, and complications of the Anser Clavicle Pin at 1-year follow-up.
A prospective explorative case series including 20 patients with displaced midshaft clavicle fractures was performed in 2 hospitals. The primary outcomes were union rate, functional outcomes (Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score), and complications. The secondary outcomes were closed reduction rate, operative time, image-intensifier time, hospital stay, incision length, time to radiologic union, postoperative pain reduction, reoperation rate, health-related quality-of-life score, and patient satisfaction.
There was a 100% union rate. The Constant-Murley score at 1 year was 96.7 (standard deviation [SD], 5). The Disabilities of the Arm, Shoulder and Hand score was 5.1 (SD, 10). There were no infections, neuropathy of the supraclavicular nerve, or hardware irritation requiring removal of hardware. Three device-related complications (15%) occurred, including plastic deformation, protrusion, and hardware failure. The satisfaction score was 8.9 (SD, 1) on the visual analog scale at the 1-year follow-up.
Managing displaced midshaft clavicle fractures with the Anser Clavicle Pin results in a 100% union rate and excellent functional outcomes and patient satisfaction. It has a low non–device-related complication rate, and the device-related complications that occurred in this series may be prevented in the future.
An evaluation of treatment options for medial, midshaft, and distal clavicle fractures: a systematic review and meta-analysis
2020, JSES International
The majority of clavicle fractures are midshaft injuries, although fractures of the distal or medial fragment also occur. The aim of this study was to review the current evidence on these injuries to help inform future treatment plans.
We searched for studies comparing interventions for medial, midshaft, or distal clavicle fractures; however, we did not identify any comparative studies on medial fractures and performed a secondary search on this topic. We conducted Bayesian network meta-analyses, although this was not feasible with studies on medial fractures and we described their results qualitatively.
For midshaft fractures, we found statistically significant improvements in function and time to radiographic union with plating, an elastic stable intramedullary nail (ESIN), and the Sonoma CRx intramedullary nail over nonoperative treatments. Both plating and an ESIN also showed significantly lower risks of nonunion and malunion relative to nonoperative methods. For distal fractures, a locking plate (LP) with or without coracoclavicular (CC) suturing yielded significantly better outcomes over K-wires with or without tension bands, CC suturing alone, an LP with a CC screw, a hook plate, and a sling. For medial fractures, plating may result in more favorable functional and union-related outcomes, although implant irritation may occur. In addition, K-wires, tension bands, and a screw with sutures demonstrated success when plating was technically not feasible in a few cases, whereas treatment with a sling may result in reduced function and a higher risk of complications relative to surgery.
This study can provide guidance on the management of medial, midshaft, and distal clavicle fractures. The current evidence suggests that plating, an ESIN, and a CRx intramedullary nail are all good options for midshaft fractures; an LP with or without CC suturing should be preferred for distal fractures; and plating is also acceptable for medial fractures, provided that the patient is deemed suitable for surgery and has the adequate bone stock and sufficiently sized medial fragment necessary to implant the device. Patient preferences for certain outcomes should be considered, which may result in different treatment recommendations.
Postoperative chest radiograph after open reduction internal fixation of clavicle fractures: a necessary practice?
2019, Journal of Shoulder and Elbow Surgery
Iatrogenic pneumothorax is a rare but serious complication of open reduction and internal fixation (ORIF) of clavicular fractures. Many institutions use postoperative chest radiographs to evaluate for this complication despite a lack of data to support this routine practice. Due to concerns of radiation exposure and health care costs, this practice may not be necessary. This study determined the rate of iatrogenic pneumothorax after clavicular ORIF with plate fixation at a single institution over 8 years. We hypothesized that postoperative chest radiographs would identify a very low rate of pneumothorax in patients with isolated clavicular fractures with no serious preoperative pulmonary injury.
A retrospective review was performed identifying all patients undergoing clavicular ORIF with plate fixation at a single Level I trauma center by 3 board-certified orthopedic surgeons from 2009 to 2017. Patients without at least 1 postoperative chest radiograph were excluded. We determined patient demographics and rate of preoperative and postoperative pneumothorax.
We identified 89 patients without preoperative pneumothorax who underwent clavicular ORIF with at least 1 postoperative chest radiograph. Within this group, no patients (0%) had a new postoperative iatrogenic pneumothorax.
Within this series of 89 patients with isolated clavicular fractures without preoperative pneumothorax, no iatrogenic pneumothoraces occurred after plate fixation. Therefore, for patients undergoing ORIF of isolated clavicular fractures obtaining a postoperative chest radiograph may be an unnecessary practice, especially given their low sensitivity. Future high-powered studies are needed to validate this finding.
Distal clavicle fracture treated with a titanium elastic nail (TEN)
2019, Trauma Case Reports
It is generally known to use internal fixation using a hook plate or Kirschner wire as an operative treatment for distal clavicle fracture. TEN is a surgical technique that is mainly used in clavicle mid-shaft fracture, and there is no reported case for distal clavicle. We report a case of distal clavicle fracture treated with TEN. A 19-year-old man came to the emergency department with right shoulder pain after bicycle accident. The radiographs showed a distal clavicle fracture without apparent disruption of the acromioclavicular joint (AC-joint) and classification with a Neer type IIA fracture pattern. One day after trauma the patient was treated with closed reduction and internal fixation using a titanium elastic nail (TEN). At 6 months postoperatively, there was no complication and radiograph showed good distal clavicle union. Therefore we performed removal of a TEN.

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: Drs Yun-Feng Chen and Hai-Feng Wei contributed equally to the work and this manuscript.

: No ethical or review board approval was obtained for this study (not applicable).

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ShoulderRetrospective comparison of titanium elastic nail (TEN) and reconstruction plate repair of displaced midshaft clavicular fractures

Background

Materials and methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Conclusion

Acknowledgments

Disclaimer

Orthop Clin North Am

Injury

J Shoulder Elbow Surg

Injury

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Orthop Sci

Complications of plate fixation in fresh displaced midclavicular fractures

J Trauma

Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture

J Bone Joint Surg Am

Anterior-inferior Plate fixation of middle third fractures and nonunions of the clavicle

J Orthop Trauma

Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail problems and complications

Am J Sports Med

The influence of induced micromovement upon the healing of experimental tibial fractures

J Bone Joint Surg Br

Closed treatment of displaced middle-third fractures of the clavicle gives poor results

J Bone Joint Surg Br

Elastic stable intramedullary nailing of midclavicular fractures in athletes

Br J Sports Med

Technique of intramedullary osteosynthesis of the clavicle with elastic titanium nails

Unfallchirurg

Shoulder
Retrospective comparison of titanium elastic nail (TEN) and reconstruction plate repair of displaced midshaft clavicular fractures