[A retrospective study on manual reduction combined with Chinese Orthopaedic ankle external fixator in the treatment of trimalleolar fracture].

OBJECTIVE: To evaluate the needle puncture safety and clinical efficacy of manual reduction combined with external fixation of ankle frame in the treatment of trimalleolar fracture under the guidance of Chinese Osteosynthesis (CO) theory. METHODS: The clinical data of 118 patients with trimalleolar fractures admitted from December 2010 to December 2021 were retrospectively analyzed. Fifty-three patients were treated with manual reduction combined with external fixation of ankle frame(observation group). Sixty-five patients were treated with open reduction and internal fixation with plate and screws(control group). The operation time, hospitalization days, non-weight-bearing time of the affected limb, clinical healing time of fracture, incidence of complications, visual analogue scale (VAS) before and 1 month after operation, and American Orthopedic Foot and Ankle Society(AOFAS) score of ankle joint before and 1 year after operation were compared between the two groups. RESULTS: Patients in both groups were followed up for more than 1 year. All patients were followed up, and the duration ranged from 14 to 70 months, with an average of(35.28±14.66) months. There were statistically significant in operation time, hospitalization days, non-load-bearing time of affected limbs, clinical healing time of fractures and VAS score one month after operation between the two groups. One month after operation, the VAS score of the observation group was lower than that of the control group(t=3.343, P=0.001). The operation time of the observation group was significantly shorter than that of the control group(t=9.091, P=0.000). The hospitalization days in the observation group were significantly less than those in the control group(t=5.034, P=0.000). The non-load-bearing time of the affected limb in the observation group was significantly shorter than that in the control group(t=11.960, P=0.000). The clinical healing time of fracture in the observation group was significantly shorter than that in the control group(t=4.007, P=0.000). There was no significant difference in AOFAS score between the two groups one year after operation(t=0.417, P=0.678). In the observation group, there were 2 cases of pinhole infection and 3 cases of loss of reduction less than 2 mm. There were 3 cases of surgical incision infection in the control group. There was no significant difference in the incidence of complications between the two groups(χ2=0.446, P=0.504). CONCLUSION: Manual reduction combined with external fixation is safe and effective in the treatment of trimalleolar fracture under the guidance of CO theory, and the function of ankle joint recovers well after operation. This therapy has good clinical value.

Mandibular Subcondylar Fracture: Improved Functional Outcomes in Selected Patients with Open Treatment.

BACKGROUND: Subcondylar fractures represent 25 to 35 percent of all mandibular fractures, yet the treatment paradigm has remained controversial. Closed treatment relies on the plasticity of the condyle head during recovery, whereas open treatment is challenging and risks facial nerve injury. Perioperative, functional, and patient-reported outcomes were measured to compare methods of open versus closed treatment of subcondylar fractures. METHODS: Selected displaced subcondylar fracture cases with open (open reduction and internal fixation of subcondylar fracture with maxillomandibular fixation) versus closed (maxillomandibular fixation) treatment were compared (n = 60). Demographics, perioperative data, complications, persistent symptoms, chin deviation, malocclusion, change in mouth opening, functional scores, and FACE-Q patient satisfaction were recorded. RESULTS: Open versus closed groups had similar demographics and perioperative data, except the open group had longer operating room time (76.39 minutes versus 56.15 minutes). In long-term follow-up, open-treated patients had fewer symptoms (9 percent versus 67 percent), less chin deviation (0 percent versus 40 percent), a less restricted mouth opening (3mm versus 5mm), and better functional scores (1.92 versus 0.861). Transient facial nerve weakness was seen in 6 percent of open cases. CONCLUSION: For selected subcondylar fracture patients, open treatment with endoscopic assistance, nerve monitoring, and specialized plates provides superior long-term results compared to closed treatment when considering symptoms and functional parameters. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Therapeutic analysis of Herbert screw fixation for capitellar fractures via the anterior approach in adolescent patients.

OBJECTIVE: The aim of this study is to analyze the efficacy of open reduction and Herbert screw fixation for coronal fractures of the capitellum via the anterior approach in adolescents. METHODS: We retrospectively analyzed the clinical and imaging data of 15 adolescents with capitellar fractures who were admitted to our hospital from May 2014 to May 2019. The fracture was reduced through the cubital crease incision via the anterior approach and was internally fixated with Herbert screws. A follow-up was conducted after the operation to examine fracture healing and elbow function. The postoperative functional recovery of patients was evaluated with the Mayo Elbow Performance index (MEPI) and the Broberg-Morrey rating system. RESULTS: Patients underwent surgery 3.7 days after injury on average. Intraoperative fracture reduction was satisfactory. No vascular injury or nerve injury occurred. Bony union occurred in an average of 6 weeks after the operation. All adolescents completed a 12- to 36-month follow-up. At the last follow-up, the Mayo Elbow Performance index was considered excellent in 12 patients and good in three patients. The Broberg-Morrey score was considered excellent in 12 patients, good in two patients, and fair in one patient. CONCLUSION: Open reduction with Herbert screw fixation via the anterior approach is a feasible surgical method for the treatment of coronal fractures of the capitellum in adolescents. LEVELS OF EVIDENCE: Therapeutic, retrospective study-Level IV.

The comparison of Nice knots and traditional methods as an auxiliary reduction-fixation technique in pre-contoured locking plate fixation for comminuted Robinson type 2B clavicle fracture: A retrospective study.

ABSTRACT: Open reduction and pre-contoured locking plate fixation is a popular treatment option for displaced midshaft clavicle fracture. Lag screw and cerclage are 2 main intraoperative techniques to reduce and fix fragments. However, both lag screw and metallic cerclage have disadvantages. The doubled-suture Nice knot has been reported in many areas of orthopedic surgery for its effectiveness. This study aims to compare the outcomes of comminuted mid-shaft clavicle fractures reduced by Nice knots vs traditional techniques (lag screw or/and metallic cerclage) when bridged with pre-contoured locking plates.We retrospectively reviewed 101 patients (65 females and 36 males) diagnosed with midshaft clavicle fractures with at least one wedge fragment reduced by either Nice knots or traditional methods and bridged with pre-contoured locking plates between December 2016 and April 2019. Operation time, functional outcomes, pain, patient satisfaction, fracture healing, and complications were assessed at a follow-up of 12 to 40 months.The mean age of all the patients was 50.8 years. There were 52 and 49 patients in the Nice knot group and traditional group respectively, and no differences between 2 groups were found in general patient characteristics, fracture type, follow up and injury-to-surgery duration. The Nice knot group had significant less operation time (P < .01) than the traditional group (mean and standard deviation [SD], 78.6 ±â€Š19.0 compared with 94.4 ±â€Š29.9 minutes, respectively). For healing time, functional score, pain, satisfaction and complications, there were no significant differences between groups, despite the Nice knot group had slightly better results.Both Nice knots and traditional methods treated for comminuted Robinson type 2B clavicle fractures were effective and safe. And the Nice knots seemed to be superior with significant less operation time.

Two-stage strategy for neglected Monteggia fracture in children: A retrospective study of 51 patients.

ABSTRACT: A neglected Monteggia fracture is defined as the fracture of the proximal ulna associated with radial head dislocation (RHD) without undergoing any treatment for 4 weeks or more after injury. One-stage operation of ulnar corrective osteotomy and open reduction of RHD might result in many complications. Therefore, a two-stage strategy, including ulnar osteotomy (UO) with or without annular ligament reconstruction (ALR), was adopted at our institute since 2010.We performed a retrospective review of 51 patients with neglected Monteggia fracture between January 2010 and January 2018. Patients with bilateral problems or concomitant injuries in the ipsilateral extremity were excluded. Radiological and clinical data were collected from Hospital Database and clinical visits. All patients were divided into 2 groups based on the status of the ALR: the UO alone (UO) group and the ALR group.There were 15 patients in the UO group and 36 patients in the ALR group. The age in the UO group (6.1 ±â€Š2.3, year) was significantly younger than the ALR group (9.8 ±â€Š2.8, year) (P < .001). Concerning the duration from initial injury to surgery, there was a significant difference between the UO group (8.6 ±â€Š3.2 months) and the ALR group (23.3 ±â€Š12.6 months, P < .001). Concerning the preoperative elbow function, there was no significant difference between the UO group (67.6 ±â€Š5.0) and the ALR group (66.6 ±â€Š4.4) according to the Mayo elbow performance score (MEPS) (P = .51). Concerning the postoperative parameters, including postoperative ROM of the joint, removal of external fixator (6.7 ±â€Š0.8, 6.9 ±â€Š0.9 weeks) (P = .55), lengthening (8.9 ±â€Š2.5, 10.3 ±â€Š2.5 mm) (P = .10) and MEPS (92.7 ±â€Š2.1, 91.6 ±â€Š2.1) (P = .08), there was no significant difference between the UO group and ALR group.Two-stage strategy is a reasonable choice for selected patients with long-lasting RHD with ulnar deformity.

Early complications and reoperation rates are similar amongst open reduction internal fixation, intramedullary nail, and distal femoral replacement for periprosthetic distal femur fractures: a systematic review and meta-analysis.

BACKGROUND: Our purpose was to perform a systematic review and meta-analysis to evaluate complication and revision rates for periprosthetic distal femur fractures (PPDFF) treated with: (1) ORIF using periarticular locking plates (ORIF), (2) retrograde intramedullary nail (IMN), and (3) distal femoral replacement (DFR). METHODS: Systematic review of the literature was performed to identify eligible studies (N = 52). Identified treatment groups were: ORIF (N = 1205 cases), IMN (N = 272 cases), and DFR (N = 353 cases). Median follow-up was 30 months (range 6-96 months). Primary outcomes were: (1) major complication rates and (2) reoperation rates over the follow-up period. Secondary outcomes were incidence of deep infection, periprosthetic fracture, mortality over the follow-up period, 1-year mortality, non-union, malunion, delayed union, and hardware failure. Data for primary and secondary outcomes were pooled and unadjusted analysis was performed. Meta-analysis was performed on subset of individual studies comparing at least two of three treatment groups (N = 14 studies). Odds-ratios and their respective standard errors were determined for each treatment group combination. Maximum likelihood random effects meta-analysis was conducted for primary outcomes. RESULTS: From the systematic review, major complication rates (p = 0.55) and reoperation rates (p = 0.20) were not significantly different between the three treatment groups. DFR group had a higher incidence of deep infection relative to IMN and ORIF groups (p = 0.03). Malunion rates were higher in IMN versus ORIF (p = 0.02). For the meta-analysis, odds of major complications were not significantly different between IMN versus DFR (OR 1.39 [0.23-8.52]), IMN versus ORIF (OR 0.86 [0.48-1.53]), or the ORIF versus DFR (OR 0.91 [0.52-1.59]). Additionally, odds of a reoperation were not significantly different between IMN versus DFR (OR 0.59 [0.08-4.11]), IMN versus ORIF (OR 1.26 [0.66-2.40]), or ORIF versus DFR (OR 0.91 [0.51-1.55]). CONCLUSIONS: There was no difference in major complications or reoperations between the three treatment groups. Deep infection rates were higher in DFR relative to internal fixation, malunion rates were higher in IMN versus ORIF, and periprosthetic fracture rates were higher in DFR and IMN versus ORIF.

Comparable results using 2.0-mm vs. 3.5-mm screw augmentation in midshaft clavicle fractures: a 10-year experience.

PURPOSE: Absence of cortical alignment in wedge-shaped and multifragmentary fractures (Fx) results in decreased fixation stability. The aim of this study was to compare the outcome using 2.0- vs. 3.5-mm screws for open reduction and internal fixation (ORIF) in dislocated, wedge-shaped or fragmentary midshaft clavicle fractures. MATERIALS AND METHODS: Patients suffering from AO/OTA 15 2.A-C midshaft clavicle fractures were operatively treated between 2008 and 2018. 2.0- or 3.5-mm cortical screws were used to restore anatomic alignment in dislocated, wedge-shaped and fragmentary clavicle fractures. Data of radiologic outcome were collected until fracture consolidation was identified. RESULTS: 80 consecutive patients with a mean age of 44.5 ± 16.3 years, who were operatively treated for dislocated midshaft clavicle fractures were enrolled. 40 patients were treated using 2.0-mm and 40 patients using routine 3.5-mm cortical screws, respectively. Time to fracture consolidation was 12.8 ± 7.8 months. No mal- or non-unions occurred during routine follow-up until 18 months postoperatively. CONCLUSION: Restoring anatomic alignment in wedge or fragmentary clavicle fractures can ultimately be addressed using cortical screw augmentation. Both groups showed comparable results with respect to fracture reduction, fixation and stability as well as time to consolidation of the fracture, while the 2.0-mm screw diameter was associated with easier handling of small Fx fragments.

Broken guidewire intramedullary: what to do now?

Instrument breakage during orthopaedic procedures is relatively uncommon, but it remains a challenging problem to orthopaedic surgeons. We report a case of a broken guidewire during intramedullary nail fixation of a proximal femur fracture with subtrochanteric extension. We also report a simple yet effective technique for removal of a broken guidewire from the medulla of the proximal femur without causing much iatrogenic trauma.

Combined palmar and dorsal plating of four-part distal radius fractures: Our clinical and radiological results.

OBJECTIVES: This study aims to investigate the radiological and clinical outcomes of four-part intraarticular distal radius fractures treated with a volar anatomically locked plate and 2 mm low-profile plates using both the volar and dorsal approaches. PATIENTS AND METHODS: This retrospective study included 20 patients (8 males, 12 females; mean age 47±12.1; range, 25 to 67 years) who received open reduction and internal fixation with combined volar and dorsal plating to treat complex four-part distal radius fractures (shaft, radial styloid area, dorsal medial facet, volar medial facet) between May 2016 and January 2019. According to Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, all fractures were 2R3-C3. According to Melone classification, one fracture was type 1, seven fractures were type 2a, three were type 2b, three were type 3 and six were type 4. The mean follow-up time was 21±7.5 (range, 12 to 36) months. RESULTS: Union was achieved in all fractures. The mean tourniquet time was 103±12 (range, 90 to 130) minutes. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 10±9, and the mean Visual Analog Scale score was 2.1±0.9. According to Mayo wrist score, five patients had excellent, six had good, six had satisfactory and three had poor results. The mean grip strength was 25.2±9.2 (range, 15 to 40) kg and 78% of opposite side. Mean wrist flexion was 48.7°±15.3° (range, 30° to 80°), extension was 52.2°±17.2° (range, 25° to 80°), radio-ulnar deviation arc was 40.7°±6.9° (range, 30° to 55°), and mean forearm rotation arc was 152.3°±11° (range, 130° to 170°). CONCLUSION: Plating method with a dual approach may be an alternative for four-part intraarticular distal radius fractures given its early mobility advantage and satisfactory functional and radiological results.

Open Reduction and Long Locking Plate Fixation of Complex Proximal Humeral Metadiaphyseal Fractures.

BACKGROUND: A minority of proximal humeral fractures extend into the diaphysis and their optimal treatment remains controversial. We evaluated the outcomes and risk of complications in patients with these injuries, treated by a protocol of open reduction and long locking plate fixation (LPF). METHODS: Between 2007 and 2014, all locally resident patients with a proximal humeral fracture extending into the diaphysis were referred to a specialist shoulder clinic. Operative treatment using a protocol of open reduction and LPF was offered to medically fit patients. Those with 2-year radiographic follow-up were included in the study, and standardized assessments of clinical and radiographic outcomes were performed during the first 2 years postoperatively. At a mean of 8.8 years (range, 5 to 12 years) after LPF, the functional outcomes and satisfaction of surviving, cognitively intact patients were assessed with a questionnaire study. RESULTS: One hundred and two patients met the inclusion criteria; the majority were older women who had incurred the injury during a simple fall. Fractures were divided into 2 types depending on the pattern of diaphyseal extension. The pain levels, functional scores, and satisfaction with treatment were satisfactory both at the 2-year follow-up and at the longer-term follow-up at a mean of 8.8 years postsurgery. Complications were predominantly due to postsurgical stiffness (in 7 patients, with 3 undergoing additional surgery) and nonunion or fixation failure (in 7 patients, with 6 undergoing additional surgery). CONCLUSIONS: Proximal humeral fractures with diaphyseal extension are rare. The results of our study support the use of LPF in medically stable patients in centers with the expertise to perform these procedures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative tibial plateau fracture during bone preparation in a cruciate retaining primary total knee arthroplasty.

Intraoperative fractures are a rare complication in total knee arthroplasty. Limited literature exists in regard to the incidence, mechanism of injury and management of intraoperative fractures. The authors report a unique case of an 80-year-old man who sustained a medial tibial plateau fracture that occurred intraoperatively during final tibia bone preparation with the use of the Woolley Tibia Punch (Innomed, Savannah, Georgia, USA). The fracture was managed with the addition of 4.5 mm cortical lag screws and the addition of a stemmed tibial implant to bypass the fracture. This is the first reported case in literature that describes an intraoperative medial tibial plateau that occurred through the use of a Woolley Tibia Punch. The authors recommend the consideration of drilling to prepare sclerotic bone for cement penetration rather than a punch in order to minimise the potential for intraoperative fractures that may occur with the use of a punch.

Coronal Hamate Fractures with Carpometacarpal Dislocation Treated Effectively Using Headless Compression Screws with Percutaneous Pinning Fixation by Using the 2-Directional Approach: A Report of 2 Cases.

CASE: Coronal shear fractures of the hamate are relatively rare injuries. Surgical intervention is recommended for displaced fractures. However, there is no established surgical procedure for the displaced coronal shear fractures of the hamate. Therefore, we present 2 cases of the displaced coronal hamate fracture with metacarpal dislocations, which were successfully managed with open reduction and internal fixation, using the headless compression screw by the 2-directional approach. CONCLUSION: Our procedure ensured that the screw's distal end captured the hamate hook, and the displaced bone fragments were reduced considerably in both cases.

Capitellum fractures: Treatment with headless screws and outcomes.

OBJECTIVES: This study aims to present the results of 21 patients with capitellum fractures treated with open reduction and headless screws by a single experienced surgeon. PATIENTS AND METHODS: Twenty-one patients (13 males, 8 females; mean age 39 years; range, 18 to 63 years) who were admitted to our clinic between June 2011 and January 2018 with the diagnosis of capitellum fracture and followed-up for a mean period of 45 months (range, 12 to 90 months) were included in this retrospective study. The fractures were fixed with headless cannulated screws by a single surgeon. RESULTS: The mean range of motion was 102° (range, 65° to 140°) during flexion-extension and 165° (range, 130° to 180°) during supination-pronation. The mean preoperative visual analog scale (VAS) score was 8.5 (range, 6 to 10), whereas the mean postoperative VAS score was 2.2 (range, 0 to 6). According to the Mayo Elbow Performance score, nine patients were evaluated as excellent, six patients as good, four patients as fair, and two as poor. The mean Quick-Disabilities of the Arm, Shoulder and Hand score was 25.1 (range, 4 to 57). Avascular necrosis developed in three patients (14%) and heterotopic ossification was detected in one patient (4%). CONCLUSION: Capitellum fractures are difficult to diagnose and treat, and good results can only be achieved by an accurate diagnosis, careful surgical technique, and stable fixation. Larger and more comprehensive studies are required to establish a generalization and more accurate inferences on this limitedly studied subject.

Elbow Fractures.

The elbow joint consists of the humeroulnar, humeroradial, and proximal radioulnar joints. Elbow stability is maintained by a combination of static and dynamic constraints. Elbow fractures are challenging to treat because the articular surfaces must be restored perfectly and associated soft tissue injuries must be recognized and appropriately managed. Most elbow fractures are best treated operatively with restoration of normal bony anatomy and rigid internal fixation and repair and/or reconstruction of the collateral ligaments. Advanced imaging, improved understanding of the complex anatomy of the elbow joint, and improved fixation techniques have contributed to improved elbow fracture outcomes.

Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate.

BACKGROUND: Locking plate technology has increased the frequency of open reduction and internal fixation (ORIF) of proximal humerus fractures (PHF). A number of technical pearls have been recommended to lower the complication rate of ORIF. These pearls are particularly relevant for patients aged >60 years, when nonoperative treatment and arthroplasty are alternatives commonly considered. There have been few large, single-center studies on the modern application of this technology. METHODS: Between 2005 and 2015, a total of 173 PHFs in patients aged >60 years were treated at our institution with ORIF using locking plates. Failure was defined as reoperation or radiographic evidence of failure. Average follow-up was 6.1 years. RESULTS: There was an overall complication rate of 44%. The overall failure rate was 34% and correlated with fracture type: 26% failure rate in 2-part fractures (16 failures), 39% in 3-part fractures (23 failures), and 45% in 4-part fractures (11 failures). There was no difference between the failure rate with and without fibular allograft (33% vs. 34%). Most patients with radiographic or clinical failure did not undergo reoperation. The overall reoperation rate was 11% (14 patients). Seven percent of 2-part fractures (4 shoulders), 14% of 3-part fractures (8 shoulders), and 18% of 4-part fractures (2 shoulders) required reoperation. CONCLUSIONS: ORIF of PHFs with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate. There was a trend toward higher complication and failure rates in older patients and more complex fractures. Refinement in fixation techniques and indications are necessary to optimize the surgical management of PHFs.

Posterolateral clamp placement on the pelvic brim provides optimal reduction of transtectal acetabular fractures fixed through the anterior intrapelvic approach.

PURPOSE: To determine the optimal position of reduction clamps applied to reduce transtectal transverse acetabular fractures approached through the anterior intrapelvic route. METHODS: Transtectal transverse fractures were created in sawbone hemipelvis models. Fractures were reduced and held with a large pointed reduction clamp with one tine centered on the quadrilateral plate and the other placed in one of nine various positions on the pelvic brim accessible from the anterior intrapelvic (AIP) approach. Reduction was assessed by measuring maximum gapping and step-off at the joint surface. RESULTS: The posterolateral pelvic brim clamp position provided the most accurate reduction with the smallest articular fracture gap (mean 1.09 ± 1.05 mm) and step-off (mean 0.87 ± 1.35 mm). This clamp position, compared with the other positions as a whole, also yielded the highest proportion of perfect reductions (0 mm maximum displacement) for both step-off (83% vs 34%; RR 2.4, 95% CI 1.7-3.2) and gap (88% vs 49%; RR 1.8, 95% CI 1.4 to 2.2). CONCLUSIONS: When clamping transtectal fractures through the AIP approach, positioning the clamp posterolaterally on the pelvic brim appears to provide the best reduction in this fracture model.

Posterior wall acetabular fracture in a 13-year-old boy treated by open reduction and mini-plate internal fixation: long-term follow-up of 17 years.

BACKGROUND: Acetabular fractures are uncommon in children and adolescents, mainly because of predominant cartilaginous component and strong surrounding ligaments. Although acetabular fractures at this age can lead to significant disability, there is no consensus regarding management, which continues to be controversial. Particularly, long-term outcome after operative management has not been evaluated. CASE PRESENTATION: We report a case of a 13-year-old boy skeletally immature who presented with an isolated acetabular fracture involving the posterior wall secondary to a traumatic hip dislocation. A Kocher-Langenbeck approach with a surgical luxation of the hip was used for reduction and mini-plate internal fixation of the fracture. Long-term (17-year) follow-up showed a good clinical outcome and a good congruence of the. The patient has bilateral beginning osteoarthritis due to a cam configuration of both hips CONCLUSION: We describe a case of successful operative management of an acetabulum fracture in a skelettaly immature child with a long-term follow-up. Aggressive management of this rare type of fractures may lead to durable positive outcome.

Risk factors for refracture after plate removal for midshaft clavicle fracture after bone union.

BACKGROUND: Open reduction and internal fixation (ORIF) with plates and screws is one of the treatment options for clavicle fractures. However, an additional operation for implant removal after union of the fracture is commonly performed due to a high incidence of hardware irritation. Despite union of the fracture, a subsequent refracture might occur after removal of the implant which requires additional surgeries for fixation. This study aims to determine the risk factors associated with refracture of the clavicle after hardware removal. METHODS: We retrospectively reviewed the medical records of 278 patients that were diagnosed with a midshaft clavicle fracture (male 190; female 88) that had (1) undergone ORIF of the clavicle with plates and (2) received a second operation for removal of hardware after solid union of the fracture between 2010 and 2017. Their mean age was 40.1 ± 15.1 years, and mean interval from fixation to plate removal was 12.5 ± 7.5 months. The patients were then divided into two groups based on the presence of refracture (n = 20) or without refracture (n = 258). We analyzed patient demographics, interval between fixation and implant removal, fracture classification (AO/OTA, Robinson), fixation device, whether wires or interfragmentary screws were used, clavicular length, and bone diameter at the fracture site. RESULTS: The overall refracture rate was 7.2%, and the mean interval between plate removal and refracture was 23.9 days. A multivariate analysis showed that female (adjusted odds ratio [aOR] 4.74; 95% CI 1.6-14.1) and body mass index [BMI] (for every 1-unit decrease, aOR 1.25; 95% CI 1.06-1.48) were risk factors for refracture. In women, BMI was the only risk factor. The optimal BMI cutoff value was 22.73. In a female patient with a lower BMI, the refracture rate was 29.8%. CONCLUSIONS: There are no significant radiographic parameters associated with refracture. Routine plate removal in a female patient with a low BMI after bony union of a midshaft clavicle fracture is not recommended because of a high refracture rate.