Page 51 - ISAKOS 2021 Newsletter Volume 1

CURRENT CONCEPTS
02A Radiograph showing a Type-II Neer distal clavicular fracture that was treated nonoperatively.
02B Radiograph, taken 5 months after trauma, showing nonunion.
Operative Treatment
The challenge of the operative treatment of distal clavicular fractures is reflected by the numerous surgical methods that have been described in the literature for the fixation of these injuries (Table I). The major issues associated with surgical treatment are (1) obtaining fixation when there is typically only a small distal fragment for fixation, (2) prevention of nonunion, (3) recurrence of the deformity, and (4) postoperative stiffness. The surgical techniques can be roughly divided into those that involve direct repair with use of hardware, techniques to stabilize the clavicle to the coracoid, and combinations of both. Surgical approaches also can be divided into open, arthroscopic, and combined techniques.
Table 1. Literature Review of Outcomes of Various Fixation Methods for Displaced Distal Clavicular Fractures*
Study
Kwak et al. (J Orthop Trauma, 2017)
Lee et al. (Int Orthop, 2009)
No. of Complications Other than Nonunion
Pin migration (14), AC arthritis (9)
Infection (2), loss of reduction (3)
Symptomatic hardware
(17), plate displacement (1)
CC ossification (3), screw back out (2)
Treatment Method
No. of Patients
Mean Age (yr)
Mean Duration of Follow- up (mo)
Mean Functional Outcome Scores at Final Follow-up
No. of Patients with Nonunion
No. of Patients Requiring Revision Surgery for Nonunion
Fann et al. (J Trauma, 2004)
Scadden et al. (Injury, 2005)
Rokito (Bull Hosp Jt Dis, 2002)
Fazal et al. (Orthop Surg Hong Kong, 2007)
Intramedullary (transacromial Knowles pin)
Intramedullary (extra-articular malleolar screw)
32
10
14
41
80
UCLA score, 25
Oxford score, 21
Constant score, 88; ASES score, 83
0
0
0
AC arthritis (1)
Multiple transacromial 2-mm pins (S-pins)
Total 56 (15
had additional interfragmentary screws for oblique fractures, 9 had bone-grafting)
45
31
Constant Score, 96; UCLA score, 33
0
0
29
Range, 12-48
0
0
K-wire with tension band wiring
Hook plate
20
32
40
26
26
26
Constant score, 88; return to work at 3 months, 60%; return to pre-injury level of activity at 6 months, 40% Constant score, 90; return to work at 3 months, 94%; return to pre-injury level of activity at 6 months, 81%
1
0
1
0
CC stabilization with sutures
36
60
0
0
0
CC stabilization with screw
30
Range, 19-39
12
SST score, 11
0
0
Macheras et al. (Orthopedics, 2005)
CC stabilization with screw
15
27.2
16
ASES score, 97
0
0
0
ISAKOS NEWSLETTER 2021: VOLUME I 49