Summary

Dual plate fixation of displaced midshaft clavicle fractures has an eight-fold lower risk of reoperation compared to single plate fixation, while accounting for age, smoking, and high-risk fracture morphology.

Abstract

Introduction

Dual plate fixation has been proposed as a solution to the high rates of reoperation secondary to operative management of displaced midshaft clavicle fractures. Previous studies have recommended dual plating for patients specifically at higher risk of reoperation. Therefore, the purpose of this study was to compare reoperation rates among patients who underwent single superior, single anterior, and dual plating while adjusting for risk factors including age, smoking status, and high-risk fracture morphology. We hypothesized lower rates of reoperation among patients who underwent dual plate fixation.

Methods

This was a retrospective cohort study of all patients who presented with a midshaft clavicle fracture and underwent ORIF between 2007 and 2021 to our trauma/sports divisions. Patient demographics, fracture pattern, plating technique, postoperative complications, date of surgery, reoperation status, date of last follow up, and date of reoperation were documented. We report hazard ratio (HR) estimates using a multivariate multilevel mixed-effects parametric survival model, which accounted for patients with multiple reoperations and adjusted for covariates.

Results

A cohort of 395 patients (mean age 38.5±14.4 years, 81.7% male) were identified with average follow-up of 5.5±8.6 months. There were 77 z-type, 157 transverse, and 161 oblique fractures. With regards to plating technique, 152 underwent single superior plating, 149 experienced single anterior plating, and 94 had dual plating. After initial operation, there were 8 total instances of non-union (2.0%), 0 in the dual plating cohort (0%), 4 in the superior plating cohort (2.6%), and 4 in the anterior plating cohort (2.7%) (p=0.35). A total of 28 reoperations took place among 19 patients (4.8%), with 6 patients experiencing multiple reoperations.

Single plating with superior placement revealed the highest reoperation rate of 0.26 per person-years, followed by anterior placement with 0.17 per person-years, and finally dual plating with 0.02 per person-years (Figure 1). Patients who underwent single plating (either anterior or superior placement) revealed a greater rate of reoperation when compared to patients who underwent dual plating (HR: 8.3, p=0.045). Patients who underwent single plating with superior placement had a rate of reoperation ten-times greater than patients who underwent dual plating (HR:10.1, p=0.03). Patients who underwent single plating with anterior placement had a rate of reoperation six-times greater than patients who underwent dual plating (HR: 6.4, p=0.09), although not statistically significant.

Conclusion

Dual plate fixation of displaced midshaft clavicle fractures has an eight-fold lower risk of reoperation compared to single plate fixation, while accounting for age, smoking, and high-risk fracture morphology. More specifically, dual plating had lower rates of reoperation than both single plating with anterior and superior placement. Therefore, when operative management is indicated for a midshaft clavicle fracture, dual plating may be an excellent treatment alternative in patients at high risk for reoperation.