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Coracoclavicular Fixation Techniques For Neer IIb And ‘Extra-Lateral’ Fractures Of The Distal Clavicle: A Systematic Review And Case Series

Coracoclavicular Fixation Techniques For Neer IIb And ‘Extra-Lateral’ Fractures Of The Distal Clavicle: A Systematic Review And Case Series

Andreas Panagopoulos, Associate Professor, GREECE Solou Konstantina, MD, MSc, GREECE Marios Nicolaides, MSc, UNITED KINGDOM Ioannis K Triantafyllopoulos, MD, MSci, PhD, FEBOT, GREECE Antonios T. Kouzelis, MD, PhD, GREECE Zinon Kokkalis

Orthopaedic Department, Patras University Hospital, Patras, GREECE


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Summary: Coracoclavicular fixation for Type IIb/c distal clavicle fractures


Background

The interpretation of distal clavicle fractures is challenging because of the inherent
difficulty to distinguish between various fracture patterns, particularly unstable types
that are indicative for internal fixation. Unstable ‘extra-lateral’ fractures (lateral to the
coracoclavicular ligaments) with superior dislocation of medial clavicle are not included
in the modified Neer classification and due to their small size, they cannot always
afford traditional hardware. In the existing literature, there is no optimal surgical
technique for managing such fractures and are commonly included with Neer IIb
fractures. The aim of this study is to perform a systematic search of the literature to
identify all studies evaluating the effectiveness and safety of coracoclavicular fixation
techniques for managing unstable Neer IIb and extra-lateral (IIc) fractures of the distal
clavicle in skeletally mature patients, and to present the clinical and radiological
outcomes of three patients with extra-lateral fractures managed with closed loop
double button open coracoclavicular fixation at our institution.

Methods

We performed a systematic review of the literature to capture all studies evaluating the
safety and effectiveness of existing coracoclavicular loop techniques for unstable Neer
IIb and extra-lateral (IIc) fractures of the distal clavicle. We searched the PubMed
(Medline and PubMed Central), Scopus, Web of Science, Google Scholar, and
Cochrane Central Register of Controlled Trials electronic databases to retrieve studies
published between January 2000 and November 2020. We also present the clinical
and radiological outcomes of three patients with IIc fractures managed with closed loop
double button coracoclavicular fixation via an open approach at our institution. Both the
systematic review and case series were guided by a prospectively developed protocol
and the latest guidelines.

Results

Our database search yielded a total of 564 records, out of which 21 were deemed
appropriate for inclusion in our qualitative synthesis. The total number of reported IIb/c
fractures managed with a coracoclavicular stabilisation technique in all studies was
421. In total, 139 (33%) patients received arthroscopic assisted treatment and 282
(67%) patients open techniques of coracoclavicular stabilization. The reported clinical

Results

were very good to excellent in most studies, whereas the overall major and
minor complication rate was 2.6% and 12.8%, respectively. Major complications were
more frequent in arthroscopic assisted techniques (4.3%) compared to open (1.8%). All
three patients presented in our case series had maintained reduction and showed
excellent Constant and Acromioclavicular Joint Instability Score at their latest follow up.

Conclusion

The present systematic review and case series of coracoclavicular stabilization
techniques for unstable Neer IIb and extra-lateral fractures of the distal clavicle
demonstrate promising clinical outcomes, including effectiveness and safety. We
support the previously proposed modification of the Neer classification to include this
unique type of unstable extra-lateral fracture (type IIc) to allow for targeted surgical
management.


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