Recent Trends in Concomitant Distal Clavicle Excision During Rotator Cuff Repair.

The purpose of this study is to evaluate trends in distal clavicle excision (DCE) in association with arthroscopic rotator cuff repair (RCR) from 2010 to 2019. The National Surgical Quality Improvement Program database was queried to identify all patients who underwent arthroscopic RCR from January 1, 2010 to December 31, 2019, and was further subdivided into procedure type: (1) isolated RCR; and (2) RCR with arthroscopic or open DCE. The proportion of each surgery type, by year and within groups, was calculated. The Cochran-Armitage test for trend was used to analyze yearly proportions of RCR with concomitant DCE. In a sample size of 19,163 patients, the proportion of RCR with DCE decreased from 51.2% to 40.8% (r = -0.830; p = 0.003). Although the results of this study suggest that surgeons are performing fewer DCEs in the setting of RCR, many DCEs are still being done. (Journal of Surgical Orthopaedic Advances 33(2):077-079, 2024).

Distal Clavicle Fracture Repair Utilizing Plate and Suture-Button Fixation: Optimizing Intraoperative Fluoroscopy.

VIDEO AVAILABLE AT: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/distal-clavicle-fracture-repair.

Evaluating the Effect of Rotator Cuff Repair With Concomitant Distal Claviculectomy on 2 and 4 Year Reoperation Rates.

BACKGROUND: The current literature has differing views on the efficacy of concomitant distal claviculectomy (DC) during rotator cuff repair (RCR) in preventing revision surgery. Our aim was to investigate the revision surgery rate between RCR with DC and RCR without DC. METHODS: A retrospective cohort analysis was conducted using a national claims database. Patients undergoing open or arthroscopic primary RCR with or without concomitant DC were identified. The primary outcome was 4-year revision surgery rates. Univariate analysis was conducted using chi-square or Student t tests. Multivariable analysis was conducted using logistic regression, and an adjusted number needed to harm was calculated. RESULTS: A total of 131,232 patients met inclusion criteria. After logistic regression, patients undergoing RCR with DC had higher odds of requiring a subsequent DC procedure [OR; 95% CI; P-value (1.49; 1.35-1.64; P < 0.001)] but lower odds of any revision surgery (0.87; 0.80-0.91; P < 0.001) within 4 years than those who underwent RCR without DC. CONCLUSION: Although associated with a lower rate of overall revision surgeries within 2 and 4 years of RCR, those who underwent RCR with DC were 85% more likely at 2 years and 49% more likely at 4 years to undergo revision surgery of the distal clavicle than those without concomitant DC.

Smoking Is Markedly Associated With 30-Day Readmission and Revision Surgery After Surgical Treatment of Clavicle Fracture.

BACKGROUND: A recent database study found that 15.2% of clavicle fractures underwent surgical treatment. Recent evidence accentuates the role of smoking in predicting nonunion. The purpose of this study was to further elucidate the effect of smoking on the 30-day postoperative outcomes after surgical treatment of clavicle fractures. METHODS: The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent open reduction and internal fixation of clavicle fracture between 2015 and 2020. Multivariate logistic regression, adjusted for notable patient demographics and comorbidities, was used to identify associations between current smoking status and postoperative complications. RESULTS: In total, 6,132 patients were included in this study of whom 1,510 (24.6%) were current smokers and 4,622 (75.4%) were nonsmokers. Multivariate analysis found current smoking status to be significantly associated with higher rates of deep incisional surgical-site infection (OR, 7.87; 95% CI, 1.51 to 41.09; P = 0.014), revision surgery (OR, 2.74; 95% CI, 1.67 to 4.49; P < 0.001), and readmission (OR, 3.29; 95% CI, 1.84 to 5.89; P < 0.001). CONCLUSION: Current smoking status is markedly associated with higher rates of deep incisional surgical-site infection, revision surgery, and readmission within 30 days after open reduction and internal fixation of clavicle fracture.

Efficacy of intramedullary bridge fixation for midshaft clavicle fractures: a retrospective analysis of a novel technique.

BACKGROUND: The aim of this study was to explore the efficacy of a novel intramedullary fixation technique using the ortho-bridge system (OBS) for midshaft clavicle fractures. METHODS: A total of 63 patients were included in this study: 35 underwent plate internal fixation (LP group) and 28 underwent OBS intramedullary fixation (OBS group). Surgical time, intraoperative blood loss, incision length, fracture healing time, removal of the internal fixation agent, visual analog scale (VAS) score for shoulder pain, Constant-Murley shoulder score and complication occurrence were compared between the two groups. RESULTS: Preoperative general data, such as sex, age and fracture type, were not significantly different between the two groups (P > 0.05). However, the OBS group exhibited better outcomes than the LP group exhibited in terms of surgical time, intraoperative blood loss and total incision length (P < 0.05). Additionally, the OBS group exhibited a significantly shorter fracture healing time and internal-fixation removal time than the LP group exhibited (P < 0.05). The VAS scores on postoperative day 1, week 1, month 1 and month 3 were lower in the OBS group than in the LP group (P < 0.05). Furthermore, the Constant-Murley shoulder scores at 1, 3, and 6 months postoperatively were higher in the OBS group than in the LP group (P < 0.05), with no significant difference at 1 year after surgery (P > 0.05). None of the patients in the OBS group experienced scarring of the surgical incision, and 6 patients in the LP group experienced scarring of the surgical incision. Finally, the complication incidence in the OBS group was lower than that in the LP group. CONCLUSION: For midshaft clavicle fractures, OBS intramedullary fixation is better than locking-plate internal fixation because it led to less trauma, a faster recovery, better efficacy, and better esthetic outcomes and comfort. Therefore, this technique may have potential as a novel treatment for midshaft clavicle fractures. LEVEL OF EVIDENCE: III, retrospective observational study.

Multicenter, Prospective, Observational Study of Nonoperative Versus Operative Treatment for High-Energy Midshaft Clavicle Fractures.

OBJECTIVES: Evaluate if nonoperative or operative treatment of displaced clavicle fractures delivers reduced rates of nonunion and improved Disability of the Arm, Shoulder, and Hand (DASH) scores. DESIGN: Multicenter, prospective, observational. SETTING: Seven Level 1 Trauma Centers in the United States. PATIENT SELECTION CRITERIA: Adults with closed, displaced (100% displacement/shortened >1.5 cm) midshaft clavicle fractures (Orthopaedic Trauma Association 15.2) were treated nonoperatively, with plates and screw fixation, or with intramedullary fixation from 2003 to 2018. OUTCOME MEASURES AND COMPARISONS: DASH scores (2, 6 weeks, 3, 6, 12, and 24 months), reoperation, and nonunion were compared between the nonoperative, plate fixation, and intramedullary fixation groups. RESULTS: Four hundred twelve patients were enrolled, with 203 undergoing plate fixation, 26 receiving intramedullary fixation, and 183 treated nonoperatively. The average age of the nonoperative group was 40.1 (range 18-79) years versus 35.8 (range 18-74) in the plate group and 39.3 (range 19-56) in the intramedullary fixation group (P = 0.06). One hundred forty (76.5%) patients in the nonoperative group were male compared with 154 (75.9%) in the plate group and 18 (69.2%) in the intramedullary fixation group (P = 0.69). All groups showed similar DASH scores at 2 weeks, 12 months, and 24 months (P > 0.05). Plate fixation demonstrated better DASH scores (median = 20.8) than nonoperative (median = 28.3) at 6 weeks (P = 0.04). Intramedullary fixation had poorer DASH scores at 6 weeks, 3 months, and 6 months than plate fixation and worse DASH scores than nonoperative at 6 months (P < 0.05). The nonunion rate for nonoperative treatment (14.6%) was significantly higher than the plate group (0%) (P < 0.001). CONCLUSIONS: Operative treatment of displaced clavicle fractures provided lower rates of nonunion than nonoperative treatment. Except at 6 weeks, no difference was observed in DASH scores between plate fixation and nonoperative treatment. Intramedullary fixation resulted in worse DASH scores than plate fixation at 6 weeks, 3 months, and 6 months and worse DASH scores than nonoperative at 6 months. Implant removal was the leading reason for reoperation in the plate and intramedullary fixation groups, whereas surgery for nonunion was the primary reason for surgery in the nonoperative group. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Nonoperative Versus Operative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Prospective Substratified Cohort Analysis.

OBJECTIVES: To compare the clinical, radiographic, and patient-reported outcomes of nonoperative and operative treatment of adolescents with comminuted "Z-type" midshaft clavicle fractures. DESIGN: Prospective observational cohort. SETTING: Eight tertiary care pediatric centers. PATIENT SELECTION CRITERIA: Patients aged 10-18 years who were treated either operatively or nonoperatively for a diaphyseal clavicle fracture between 2013 and 2017 were screened/enrolled at the time of injury. The current subcohort analysis was derived from a larger adolescent clavicle study population of 907 patients. OUTCOME MEASUREMENTS AND COMPARISONS: Complications and validated patient-reported outcome measures (PROs):(ASES, QuickDASH, Marx Shoulder Activity Score, EQ-5D, EQ-VAS, and patient satisfaction score) were compared between operative and nonoperative cohorts. RESULTS: Eighty-one patients (69 male [85.2%], 12 female; average age 15 years [11.1-18.7]; 78 with sports participation [96.2%]) were followed through bony healing and return to sports, while 59 patients (73%) completed 2-year follow-up with PROs, 26 of whom were treated nonoperatively and 33 treated operatively. All demographic and fracture characteristics were similar (P > 0.05) between the 2-year follow-up cohorts except for fracture shortening, which was greater in the operative cohort (23 vs. 29 mm, P = 0.01). After controlling for this potential confounder through both regression and propensity matched subgroup analysis, nonoperative versus operative cohorts showed no difference in rates of nonunion (0%), delayed union (0% vs. 2.3%, P = 1.0), symptomatic malunion (2.7% vs. 0%, P = 0.4), refracture (2.7% vs. 2.2%, P = 1.0), unexpected subsequent surgery (5.4% vs. 11.4%, P = 0.45), or clinically significant complications (5.4% vs. 16%, P = 0.17). There were no differences in any PROs between cohorts, both before and after controlling for the difference in fracture shortening (all P-values >0.05). CONCLUSIONS: In this prospective comparison of complications and 2-year PROs in adolescents with comminuted Z-type clavicle fractures, nonoperative and operative treatment yielded similar outcomes. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Superior versus anteroinferior plating for mid-shaft clavicle fractures: a randomized clinical trial.

BACKGROUND: Clavicle fractures represent 2.5-4% of all fractures observed in emergency services. 80% occurs in the middle third. Treatment by plating requires a higher level of evidence. OBJECTIVE: To compare the functional outcomes of mid-shaft clavicle fractures managed with superior plating compared to anteroinferior plating. TRIAL DESIGN: A randomized, double-blind, parallel, superiority clinical trial. PATIENTS AND METHODS: Patients with fractures of the clavicles AO15B1 and AO15B2 were studied. Patients were randomized to be treated with either 3.5 mm superior or anteroinferior plating. A rehabilitation program was designed for both groups. The primary outcome measure was the Disability of Arm, Shoulder, and Hand (DASH) score; secondary outcomes included pain, union rate, and complication rates. RESULTS: Twenty-eight patients were studied and were eligible for analysis. Significant differences were found in the function assessed with the DASH score at 30 days for the superior plating compared with anteroinferior (43.74 vs. 29.26, respectively, p = 0.027), 60 days (23.97 vs. 11.18, p = 0.021), and 90 days (9.52 vs. 3.5, p = 0.016). One loosening with superficial infection was found with superior plating. CONCLUSIONS: Using an anteroinferior reconstruction plate in diaphyseal fractures offers better functional results than the upper plate in patients with fractures of the middle third of the clavicle.

ANTECEDENTES: Las fracturas de clavícula comprenden el 2.5-4% de todas las fracturas observadas en los servicios de emergencia. El 80% se presentan en el tercio medio. La posición de la placa como tratamiento requiere mayor nivel de evidencia. OBJETIVO: Comparar los resultados funcionales de las fracturas diafisarias de clavícula manejadas con placa superior versus placa anteroinferior. MÉTODO: Ensayo clínico aleatorizado, doble ciego, paralelo, de superioridad. Se estudiaron pacientes con fractura diafisaria de clavícula AO15B1 y AO15B2. Se manejaron con placa de reconstrucción de 3.5 mm colocada en forma superior o anteroinferior. Se diseñó un programa de rehabilitación para ambos grupos. El resultado primario fue medido con el cuestionario DASH y los resultados secundarios incluyeron dolor, presencia de consolidación y complicaciones. RESULTADOS: Fueron elegibles para análisis 28 pacientes. Se encontraron diferencias significativas de la escala DASH a los 30 días para la maniobra superior comparada con la inferior (43.74 vs. 29.26, respectivamente; p = 0.027), a los 60 días (23.97 vs. 11.18; p = 0.021) y a los 90 días (9.52 vs. 3.5; p = 0.016). CONCLUSIONES: El uso de placa de reconstrucción anteroinferior en las fracturas diafisarias ofrece mejores resultados funcionales en comparación con la placa superior en pacientes con fracturas de tercio medio de clavícula.

The Effect of Clavicular Tunnel Position on Reduction Loss in Patients with Acute Acromioclavicular Joint Dislocations Operated with a Single-Bundle Suspensory Loop Device.

OBJECTIVE: The treatment of acromioclavicular joint (ACJ) dislocations offers numerous options, and ongoing debates persist regarding their comparative effectiveness. Among these options, the suspensory loop device (SLD) is one of the most favored treatment modalities. Despite the observed high reduction loss rate associated with SLD, the treatment yields favorable clinical outcomes. This study aimed to investigate the clinical outcomes of patients with acute type 3 and 5 ACJ dislocations who underwent open and arthroscopic procedures using a single-bundle SLD, and to evaluate the effect of clavicular tunnel position on reduction loss. METHODS: Thirty-seven eligible patients diagnosed with acute type 3 and type 5 ACJ dislocation who underwent open and arthroscopic surgery with a single-bundle SLD between January 2015 and March 2022 were evaluated retrospectively. Demographic data and radiological measurements including coracoclavicular (CC) interval, clavicle length (CL), and implant distance (ID) were recorded. The ID/CL ratio was calculated and a value between 0.17 and 0.24 was considered as "acceptable implant position". Reduction loss and other complications were noted. Patients were divided into two groups: open (Group 1) and arthroscopic (Group 2). Constant Murray Score (CMS) and Visual Analog Scale (VAS) were used for clinical and functional outcomes. Non-parametric tests were used for statistical analysis of variables. RESULTS: The study included six females (16.2%) and 31 males (83.8%) with a mean age of 40.2 ± 14.7 years (range: 20-75). The mean follow-up period was 22.3 ± 16.7 months (range: 6-72). The average time from trauma to surgery was 6.3 ± 5.3 days (range: 1-18). At the last follow-up, the CMS was 89.3 ± 8.8 and the VAS score was 2.1 ± 0.9. The mean ID/CL ratio was 0.19 ± 0.1 and 19 patients (51.4%) were between 0.17 and 0.24. Reduction loss was observed in nine patients (24.3%). There were no significant differences between Group 1 and Group 2 regarding operation time (p = 0.998), ID/CL ratio (p = 0.442), reduction loss (p = 0.458), CMS (p = 0.325), and VAS score (p = 0.699). Of the 28 patients without reduction loss, 16 had an ID/CL ratio between 0.17 and 0.24 (p = 0.43). Furthermore, within the 0.17-0.24 interval, CMS was higher with an average of 91.8 ± 5.1 compared to the other intervals (p = 0.559). CONCLUSION: The clinical and functional outcomes of acute type 3 and type 5 ACJ dislocation operated open and arthroscopically with single-bundle SLD are similar and satisfactory. A clavicular tunnel position in the range of 0.17-0.24 (ID/CL ratio) is recommended to maintain postoperative reduction.

Management of thoracic outlet syndrome in patients with hemodialysis access.

Patients with threatened arteriovenous access are often found to have central venous stenoses at the ipsilateral costoclavicular junction, which may be resistant to endovascular intervention. Stenoses in this location may not resolve unless surgical decompression of thoracic outlet is performed to relieve the extrinsic compression on the subclavian vein. The authors reviewed the management of dialysis patients with central venous lesions at the thoracic outlet, as well as the role of surgical decompression with first-rib resection or claviculectomy for salvage of threatened, ipsilateral dialysis access.

The infraclavicular approach for venous thoracic outlet syndrome.

Venous thoracic outlet syndrome (vTOS) is an esoteric condition that presents in young, healthy adults. Treatment includes catheter-directed thrombolysis, followed by first-rib resection for decompression of the thoracic outlet. Various techniques for first-rib resection have been described with successful outcomes. The infraclavicular approach is well-suited to treat the most medial structures that are anatomically relevant for vTOS. A narrative review was conducted to specifically examine the literature on infraclavicular exposure for vTOS. The technique for this operation is described, as well as the advantages and disadvantages of this approach. The infraclavicular approach is a reasonable choice for definitive treatment of uncomplicated vTOS.

Comprehensive comparison between conservative therapy and surgical management for completely displaced and comminuted mid-shaft clavicle fractures.

PURPOSE: It is still controversial whether complete displaced mid-shaft clavicle fractures should be treated with internal fixation or conservative therapy. This retrospective study aims to compare clinical outcomes of two treatment protocols. MATERIALS AND METHODS: 105 patients with displaced and comminuted mid-shaft clavicle fractures were included in this study, among which 55 patients were treated conservatively and 50 patients accepted surgical fixation and were followed up for over 20 months on average. Rate of union, malunion, time taken for union, functional outcome, self-reported satisfaction and complications were compared. RESULTS: Union rate of operative group (n=49, 98.0%) was higher than the non-operative group (n=48, 87.3%). Time taken for union in operative group (2.37±1.06 months) was shorter than the non-operative group (3.69±1.01 months). Malunion and asymmetric were only seen in the conservative group. Numbness of the shoulder was only reported in the operative group (n=23, 46.0%). Most of patients in the operative group (n=45, 90%) accepted a second operation to remove the implant. No statistically difference was found in self-reported satisfaction, Quick-DASH and Constant-Murley score. The operative group returned to work faster (1.47±0.89 to 3.34±1.37 months), regained full range of motion earlier (1.66±0.78 to 3.83±1.24 months) and regained strength faster (3.86±2.45 to 8.03±2.78 months) than the non-operative group. CONCLUSION: Complete displaced and comminuted mid-shaft clavicle fractures treated surgically have more reliable union and faster recovery when compared to conservatively treated fractures.

Ex vivo analysis of cortical microarchitecture of the distal clavicle: implications for surgical management of fractures.

BACKGROUND: Cortical thickness and porosity are two main determinants of cortical bone strength. Thus, mapping variations in these parameters across the full width of the distal end of the clavicle may be helpful for better understanding the basis of distal clavicle fractures and for selecting optimal surgical treatment. METHODS: Distal ends of 11 clavicles (6 men, 5 women; age: 81.9 ± 15.1 years) were scanned by micro-computed tomography at 10-µm resolution. We first analyzed cortical thickness and porosity of each 500-µm-wide area across the superior surface of distal clavicle at the level of conoid tubercle in an antero-posterior direction. This level was chosen for detailed evaluation because previous studies have demonstrated its superior microarchitecture relative to the rest of the distal clavicle. Subsequently, we divided the full width of distal clavicle to three subregions (anterior, middle, and posterior) and analyzed cortical porosity, pore diameter, pore separation, and cortical thickness. RESULTS: We found the largest number of low-thickness and high-porosity areas in the anterior subregion. Cortical porosity, pore diameter, pore separation, and cortical thickness varied significantly among the three subregions (p < 0.001 p = 0.016, p = 0.001, p < 0.001, respectively). Cortex of the anterior subregion was more porous than that of the middle subregion (p < 0.001) and more porous and thinner than that of the posterior subregion (p < 0.001, p = 0.030, respectively). Interaction of site and sex revealed higher porosity of the anterior subregion in women (p < 0.001). The anterior subregion had larger pores than the middle subregion (p = 0.019), whereas the middle subregion had greater pore separation compared with the anterior (p = 0.002) and posterior subregions (p = 0.006). In general, compared with men, women had thinner (p < 0.001) and more porous cortex (p = 0.03) with larger cortical pores (p < 0.001). CONCLUSIONS: Due to high cortical porosity and low thickness, the anterior conoid subregion exhibits poor bone microarchitecture, particularly in women, which may be considered in clinical practice. LEVELS OF EVIDENCE: Level IV.

Postoperative recreational sports and subjective shoulder function: a comprehensive analysis following intramedullary stabilization of displaced midshaft clavicular fractures.

Introduction Sports-related outcomes and the role of recreational sports activities for shoulder function after intramedullary stabilization (IMS) of displaced midshaft clavicular fractures (DMCFs) in the general population are not well known. In this study, we aimed to determine the sport-related outcomes (return-to-sports [RTS] rate, type of sports, time until RTS, and intensity) and to explore the role of sports after IMS of DMCFs. Materials and Methods This single-center, retrospective, cohort study included patients who underwent IMS of DMCFs between 2009 and 2022 at a Level II trauma center in Germany, experienced no major complications, and had completed at least 1 year of follow-up. Propensity score matching was conducted to obtain a balanced sample of patients who did not engage (cases) and engaged (controls) in postoperative sports activities by adjusting for age and fracture complexity. Groups were compared to assess the impact of regular sports activities on subjective shoulder functioning at follow-up, as evaluated using the Disabilities of the Arm, Shoulder, and Hand and Oxford Shoulder Score (OSS) questionnaires, after controlling for the patient- (i.e., sex and smoking) and treatment- (i.e., surgery duration and physical therapy) factors. Results Among the 199 patients included, the RTS rate was 97.5%, and 160 patients practiced regular postoperative activity, mostly in the same sport and intensity. In the matched cohort (39 cases and 39 controls), practicing regular sports activities postoperatively was the only independent factor associated with a higher OSS in the multiple regression analysis (unstandardized regression coefficient = 2.40; Bias-corrected and accelerated 95% confidence interval [0.28, 4.69]). Conclusions The sport-related outcomes after IMS of DMCFs in our cohort were comparable to those achieved after plate osteosynthesis, and IMS reported in the literature. Recreational sports activities benefitted subjective shoulder function, thereby encouraging further research and potentially influencing management policies. Level of evidence Grade IV - a retrospective observational cohort study.

Optimizing hook implantation angle of the clavicular hook plate: a cadaveric study.

PURPOSE: While Clavicle hook plates have demonstrated favorable results regarding bone and shoulder function, their design can potentially lead to complications due to pressure concentration at the plate's tip. This study aims to investigate the impact of different hook implantation angles on the contact surface area between the hook plate and acromion, with the goal of minimizing mismatch and maximizing contact surface area. METHODS: Twenty soft shoulder cadavers were included in the study, and the contact surface area of the hook plate was measured in different positions based on the hook implantation angle. RESULTS: The results showed variations in compatibility, width, and length of the contact surface area depending on the hook implantation angle and the medial or lateral row placement. The lateral row generally demonstrated superior compatibility (84.0% vs 46.67%, p-value < 0.001), with a broader contact area (3.55 ± 0.08 mm vs 3.09 ± 0.10 mm, p-value = 0.004) and a longer contact area (7.36 ± 0.19 mm vs 5.10 ± 0.23 mm, p-value < 0.001) at specific angles. A detailed analysis of the lateral position revealed that the zero angle of implantation resulted in the greatest contact surface area, measuring 3.91 ± 0.70 mm in width (p value = 0.083) and 8.85 ± 1.24 mm in length (p value < 0.001). CONCLUSION: Placing the hook laterally and at the zero position according to the hook implantation angle can maximize contact surface area, may reduce stress concentration, and minimize complications in hook plate fixation. Further research and consideration of anatomical variations are warranted to refine the placement technique and enhance patient outcomes. LEVEL OF EVIDENCE: Level V evidence.

Usefulness of double plate fixation after failed ORIF for clavicle shaft fracture.

PURPOSE: We aimed to evaluate the clinical and radiological outcomes of double plate fixation for failed clavicle shaft fracture surgery. MATERIALS AND METHODS: We analyzed 14 patients who underwent double plate fixation due to plate failure after clavicle shaft fracture surgery from March 2016 to March 2021. The study used 3.5 mm locking compression plates for superior clavicle and anterior reconstruction in all patients. In addition, moldable allograft bone was used to fill the bone defect. Clinical and radiological evaluation was performed immediately, at 2 and 4 weeks, and 3, 6, 9, and 12 months postoperatively. The visual analog scale (VAS), University of California at Los Angeles (UCLA) shoulder scale, and American Shoulder and Elbow Surgeons (ASES) scores and range of motion of the shoulder were evaluated as clinical results. For radiological evaluation, anteroposterior, caudal, and cephalad views of both clavicles were used. Successful bone union was defined as complete adjoining of the fracture site through callus formation. RESULTS: Successful bone union was achieved in all patients, and the mean time to bone union was 16.7 ± 1.2 weeks (range, 12-24 weeks). Statistically significant improvement in forward flexion and external and internal rotation was observed from 135.5° ± 6.3, 45.2° ± 5.3, and 13° ± 2.3 preoperatively to 157.0° ± 9.3, 68.7° ± 6.3, and 9.8° ± 3.1 at the final follow-up, respectively. The VAS score improved from an average of 6.2 ± 2.8 preoperatively to 1.3 ± 0.7 at the final follow-up, which was statistically significant (P = 0.018). In addition, the ASES score significantly increased from a mean of 52.1 ± 6.3 points preoperatively to 83.6 ± 7.8 points at the final follow-up (P = 0.001). The average UCLA shoulder score was 16.7 ± 1.4 and 31.4 ± 2.2 points preoperatively and at the final follow-up, respectively, which was statistically significant (P = 0.001). CONCLUSION: Double plate fixation has shown good results after failed open reduction and internal fixation (ORIF) for clavicle shaft fractures. Therefore, in complicated situations after ORIF, double plate fixation is considered a surgical treatment option.

Clavicular tunnel widening after acromioclavicular joint reconstruction: comparison between single and double clavicular tunnel techniques.

Acromioclavicular joint (ACJ) reconstruction using artificial ligaments is a common surgical treatment for Rockwood grade III or higher injuries. These techniques use bone tunnels in the clavicle and coracoid to insert the Tightrope implants. This multicenter retrospective study compares long term radiographic follow up of clavicular tunnel widening in two groups of patients with high-grade ACJ injury who underwent reconstruction using two different surgical techniques. The first group of 23 patients underwent an arthroscopic single clavicular tunnel ACJ reconstruction. The second group of 23 patiënts underwent an open double clavicular tunnel reconstruction. Inclusion criteria are Rockwood grade III or higher injury and minimum 18 months of follow-up. Exclusion criteria are distal clavicle fracture and additional stabilization techniques. Radiographic results were measured on anteroposterior shoulder radiographs taken at the first and last follow-up. Clavicular tunnel widening is the main outcome measurement. Secondary outcomes are heterotopic ligament calcifications, migration of buttons, tunnel fracture and loss of acromioclavicular reduction. The mean clavicular tunnel widening in the single clavicular tunnel technique is 1.91 mm. In the double clavicular tunnel technique, the widening of the medial tunnel is 2.52 mm and 3.59 mm in the lateral tunnel. The difference in widening between the single tunnel and the lateral tunnel is significant (p=0.003). A very clear observation on all follow-up X-rays was a reorientation of the clavicular tunnels towards the coracoid. The double clavicular tunnel technique has more tunnel widening in both tunnels compared to the single bundle technique.

A novel surgical method for treating fractures of the middle third of the clavicle.

BACKGROUND: The clavicle is recognized as the bone most vulnerable to fractures. Moreover, approximately 80% of fractures occur in the middle third of the clavicle. Conservative treatment is associated with a higher rate of nonunion, while surgical treatment of fracture via internal fixation may have a variety of postoperative complications. Therefore, to improve patient satisfaction and reduce the complications related to internal fixation techniques, we modified the surgical approach to external fixation. OBJECTIVE: The purpose of this study was to assess the modified intervention's prospects for clinical application. METHODS: A total of 36 patients with middle clavicle fractures were treated with screw-rod external fixation between April 2015 and October 2019. We observed the operative time, intraoperative blood loss, length of hospital stay, and fracture healing time. The patients were followed up regularly, and the clinical efficacy of the modified intervention was evaluated. Finally, the patients' shoulder function was assessed based on the disabilities of the arm, shoulder, and hand (DASH) score. RESULTS: For the screw-rod external fixation, the mean operative time was found to be 48.6 ± 6.8 min, the intraoperative blood loss was 30.6 ± 17.2 mL, the length of hospital stay was 4.5 ± 1.5 days, and the fracture healing time was 2.8 ± 0.4 months. Eventually, all the patients healed well, with the combined "excellent" and "good" rate of shoulder function being assessed to be as high as 94.44%. Furthermore, the DASH scores were all less than 10, with the average score being 4.65 ± 3.34. CONCLUSIONS: The screw-rod external fixation technique offers the advantages of convenience, reliability, and good aesthetics, suggesting that it could be used as an alternative treatment method for fractures of the middle third of the clavicle.