Reverse shoulder arthroplasty megaprosthesis for surgical management of severe proximal humeral bone loss.

BACKGROUND: Shoulder arthroplasty in the setting of severe proximal humerus bone loss can be challenging. The purpose of this study was to evaluate the outcomes of a modular segmental megaprosthesis when implanted in a reverse configuration for complex primary arthroplasty, reconstruction at the time of oncologic resection, and revision shoulder arthroplasty. MATERIALS AND METHODS: A Joint Registry Database was queried to identify all shoulder arthroplasties performed at a single institution using the Comprehensive Segmental Revision System reverse shoulder arthroplasty (SRS-RSA; Zimmer Biomet). A retrospective review of electronic medical records and radiographs was performed to record demographic data, indication, outcomes, complications, and revision surgery. RESULTS: Between February 2012 and October 2022, a total of 76 consecutive SRS-RSAs were implanted. An analysis of patients with minimum 12-month follow-up yielded 53 patients with a mean follow-up of 4.1 ± 2.43 years. Surgical complication rate in this cohort was observed in 41.5% (22 of 53) of cases. Overall, the revision rate at final follow-up was 26.4% (14 of 53), with a significant difference between the primary and revision cohorts. The number of prior surgeries was a significant risk factor for revision surgery, with a hazard ratio of 1.789 (95% confidence interval 1.314-2.436, P < .001). When analyzing aseptic humeral loosening rates across study cohorts, a significant difference was found between the primary arthroplasty (0%, n = 0) and the revision arthroplasty cohorts (22.2%, n = 6) (P = .04). DISCUSSION: Reverse shoulder arthroplasty using a modular segmental megaprosthesis remains a reasonable salvage option for shoulder reconstruction in the setting of proximal humeral bone loss. Because of the substantial bone loss and soft tissue deficiencies typically present in these cases, surgeons should educate patients on the relatively high complication rate, particularly when used in the setting of a previous failed arthroplasty.

Mid- to long-term outcomes of latissimus dorsi tendon transfer for massive irreparable posterosuperior rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: This study aims to analyze the mid-to long-term results of the latissimus dorsi tendon for the treatment of massive posterosuperior irreparable rotator cuff tears as reported in high-quality publications and to determine its efficacy and safety. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and EMBASE databases were searched until December 2022 to identify studies with a minimum 4 year follow-up. Clinical and radiographic outcomes, complications, and revision surgery data were collected. The publications included were analyzed quantitatively using the DerSimonian Laird random-effects model to estimate the change in outcomes from the preoperative to the postoperative condition. The proportion of complications and revisions were pooled using the Freeman-Tukey double arcsine transformation. RESULTS: Of the 618 publications identified through database search, 11 articles were considered eligible. A total of 421 patients (432 shoulders) were included in this analysis. Their mean age was 59.5 ± 4 years. Of these, 277 patients had mid-term follow-up (4-9 years), and 144 had long-term follow-up (more than 9 years). Postoperative improvements were considered significant for the following outcome parameters: Constant-Murley Score (0-100 scale), with a mean difference (MD) = 28 points (95% confidence interval [CI] 21, 36; I2 = 89%; P < .001); visual analog scale, with a standardized MD = 2.5 (95% CI 1.7, 3.3; P < .001; I2 = 89%; P < .001); forward flexion, with a MD = 43° (95% CI 21°, 65°; I2 = 95% P < .001); abduction, with a MD = 38° (95% CI 20°, 56°; I2 = 85%; P < .01), and external rotation, with a MD = 8° (95% CI 1°, 16°; I2 = 87%; P = .005). The overall reported mean complication rate was 13% (95% CI 9%, 19%; I2 = 0%), while the reported mean revision rate was 6% (95% CI: 3%, 9%; I2 = 0%). CONCLUSIONS: Our pooled estimated results seem to indicate that latissimus dorsi tendon transfer significantly improves patient-reported outcomes, pain relief, range of motion, and strength, with modest rates of complications and revision surgery at mid-to long-term follow-up. In well-selected patients, latissimus dorsi tendon transfer may provide favorable outcomes for irreparable posterosuperior cuff tears.

Lower Trapezius Transfer Improves Clinical Outcomes With a Rate of Complications and Reoperations Comparable to Other Surgical Alternatives in Patients with Functionally Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To analyze the clinical outcomes of lower trapezius transfer (LTT) for patients with functionally irreparable rotator cuff tears (FIRCT) and summarize the available literature regarding complications and reoperations. METHODS: After registration in the International prospective register of systematic reviews (PROSPERO [CRD42022359277]), a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Inclusion criteria were English, full-length, peer-reviewed publications with a level of evidence IV or higher reporting on clinical outcomes of LTT for FIRCT. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus via Elsevier databases were searched. Clinical data, complications and revisions were systematically recorded. RESULTS: Seven studies with 159 patients were identified. The mean age range was 52 to 63 years, 70.4% of the patients included were male, and the mean follow-up time ranged between 14 and 47 months. At final follow-up, LTT lead to improvements in range of motion, with reported forward elevation (FE) and external rotation (ER) mean gains of 10° to 66° and 11° to 63°, respectively. ER lag was present before surgery in 78 patients and was reversed after LTT in all shoulders. Patient-reported outcomes were improved at final follow-up, including the American Shoulder and Elbow Society score, Shoulder Subjective Value and Visual Analogue Scale. The overall complication rate was 17.6%, and the most reported complication was posterior harvest site seroma/hematoma (6.3%). The most common reoperation was conversion to reverse shoulder arthroplasty (5%) with an overall reoperation rate of 7.5%. CONCLUSIONS: Lower trapezius transfer improves clinical outcomes in patients with irreparable rotator cuff tears with a rate of complications and reoperations comparable to other surgical alternatives in this group of patients. Increases in forward flexion and ER are to be expected, as well as a reversal of ER lag sign when present before surgery. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Deep learning to automatically classify very large sets of preoperative and postoperative shoulder arthroplasty radiographs.

BACKGROUND: Joint arthroplasty registries usually lack information on medical imaging owing to the laborious process of observing and recording, as well as the lack of standard methods to transfer the imaging information to the registries, which can limit the investigation of various research questions. Artificial intelligence (AI) algorithms can automate imaging-feature identification with high accuracy and efficiency. With the purpose of enriching shoulder arthroplasty registries with organized imaging information, it was hypothesized that an automated AI algorithm could be developed to classify and organize preoperative and postoperative radiographs from shoulder arthroplasty patients according to laterality, radiographic projection, and implant type. METHODS: This study used a cohort of 2303 shoulder radiographs from 1724 shoulder arthroplasty patients. Two observers manually labeled all radiographs according to (1) laterality (left or right), (2) projection (anteroposterior, axillary, or lateral), and (3) whether the radiograph was a preoperative radiograph or showed an anatomic total shoulder arthroplasty or a reverse shoulder arthroplasty. All these labeled radiographs were randomly split into developmental and testing sets at the patient level and based on stratification. By use of 10-fold cross-validation, a 3-task deep-learning algorithm was trained on the developmental set to classify the 3 aforementioned characteristics. The trained algorithm was then evaluated on the testing set using quantitative metrics and visual evaluation techniques. RESULTS: The trained algorithm perfectly classified laterality (F1 scores [harmonic mean values of precision and sensitivity] of 100% on the testing set). When classifying the imaging projection, the algorithm achieved F1 scores of 99.2%, 100%, and 100% on anteroposterior, axillary, and lateral views, respectively. When classifying the implant type, the model achieved F1 scores of 100%, 95.2%, and 100% on preoperative radiographs, anatomic total shoulder arthroplasty radiographs, and reverse shoulder arthroplasty radiographs, respectively. Visual evaluation using integrated maps showed that the algorithm focused on the relevant patient body and prosthesis parts for classification. It took the algorithm 20.3 seconds to analyze 502 images. CONCLUSIONS: We developed an efficient, accurate, and reliable AI algorithm to automatically identify key imaging features of laterality, imaging view, and implant type in shoulder radiographs. This algorithm represents the first step to automatically classify and organize shoulder radiographs on a large scale in very little time, which will profoundly enrich shoulder arthroplasty registries.

Substantial influence of psychological factors on return to sports after anterior shoulder instability surgery: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to (1) determine the proportion of patients who underwent anterior shoulder instability surgery and did not return to sports for psychological reasons and (2) estimate differences in psychological readiness scores between patients who did and did not return to sports. METHODS: The EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE and Cochrane Library databases were searched for relevant studies. The data synthesis included the proportion of patients who did not return to sports for psychological reasons and the mean differences in the psychological readiness of athletes who returned and those who did not return to sports. Non-binomial data were analysed using the inverse-variance approach and expressed as the mean difference with 95% confidence intervals. RESULTS: The search yielded 700 records, of which 13 (1093 patients) were included. Fourteen psychological factors were identified as potential causes for not returning to sports. The rates of return to sports at any level or to the preinjury level were 79.3% and 61.9%, respectively. A total of 55.9% of the patients cited psychological factors as the primary reason for not returning to sports. The pooled estimate showed that patients who returned to sports had a significantly higher Shoulder Instability-Return to Sport After Injury score (P < 0.00001) than those who did not, with a mean difference of 30.24 (95% CI 24.95-35.53; I2 = 0%; n.s.). CONCLUSIONS: Psychological factors have a substantial impact on the rate of return to sports after anterior shoulder instability surgery. Patients who returned to sports had significantly higher psychological readiness than those who did not return to sports. Based on these results, healthcare professionals should include psychological and functional measurements when assessing athletes' readiness to return to sports. LEVEL OF EVIDENCE: Level IV.

Venous thromboembolism following surgical management of proximal humerus fractures: a systematic review.

Background: Currently, there is limited information on the incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgical treatment of proximal humerus fractures (PHFs). Therefore, the purpose of this systematic review is to evaluate the incidence of VTE, DVT, and PE following surgery for PHFs. Methods: A comprehensive search of several databases was performed from inception to May 27, 2022. Studies were screened and evaluated by 2 reviewers independently utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Only original, English studies that evaluated the incidences of VTE following surgical management of PHFs were included. Surgical procedures consisted of shoulder arthroplasty (SA) including both hemiarthroplasty (Hemi) and reverse shoulder arthroplasty (RSA) in addition to open reduction and internal fixation (ORIF). A pooled incidence for postoperative DVT, PE, and overall VTE was reported. Results: Twelve studies met the inclusion and exclusion criteria, encompassing a total of 18,238 patients. The overall DVT, PE, and VTE rates were 0.14%, 0.59%, and 0.7%, respectively. VTE was more frequently reported after SA than ORIF, (1.27% vs. 0.53%, respectively). Among SA patients, a higher rate of DVT was seen with RSA (1.2%) with the lowest DVT rate was observed for ORIF with 0.03%. Conclusions: Symptomatic VTEs following surgical treatment of PHFs, are rare, yet still relevant as a worrisome postoperative complication. Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate.

Current clinical applications of artificial intelligence in shoulder surgery: what the busy shoulder surgeon needs to know and what's coming next.

Background: Artificial intelligence (AI) is a continuously expanding field with the potential to transform a variety of industries-including health care-by providing automation, efficiency, precision, accuracy, and decision-making support for simple and complex tasks. Basic knowledge of the key features as well as limitations of AI is paramount to understand current developments in this field and to successfully apply them to shoulder surgery. The purpose of the present review is to provide an overview of AI within orthopedics and shoulder surgery exploring current and forthcoming AI applications. Methods: PubMed and Scopus databases were searched to provide a narrative review of the most relevant literature on AI applications in shoulder surgery. Results: Despite the enormous clinical and research potential of AI, orthopedic surgery has been a relatively late adopter of AI technologies. Image evaluation, surgical planning, aiding decision-making, and facilitating patient evaluations over time are some of the current areas of development with enormous opportunities to improve surgical practice, research, and education. Furthermore, the advancement of AI-driven strategies has the potential to create a more efficient medical system that may reduce the overall cost of delivering and implementing quality health care for patients with shoulder pathology. Conclusion: AI is an expanding field with the potential for broad clinical and research applications in orthopedic surgery. Many challenges still need to be addressed to fully leverage the potential of AI to clinical practice and research such as privacy issues, data ownership, and external validation of the proposed models.

Straight antegrade humeral nailing and risk of iatrogenic injury of supraspinatus tendon footprint: An MRI study.

Background: Straight antegrade humeral nailing (SAHN) is associated with excellent clinical results in proximal humerus fractures. The optimal entry point is the top of the humeral head. However, the anatomy is variable, and the entry point can affect supraspinatus tendon footprint (SSP-F) or fracture reduction. The aim of this study was to analyze the relationship between the SSP-F and SAHN entry point by analyzing magnetic resonance imaging (MRI) studies of the humerus. Methods: In total 58 MRI studies of entire humerus were reviewed. The mean age was 51.6 ± 12.4 years, with 40 female patients. The distance between the SSP-F and the SAHN insertion point (critical distance: CD), the width of the footprint, and the neck-shaft angle (NSA) were measured. Univariate and multivariate analysis were performed. Results: The mean CD was 7.51 mm ± 2.81 (0-12.9 mm) with 51.7% of proximal humerus "critical type" (CD <8 mm). The CD was found to be lower in females, with no difference found with varying age (62.5% "critical type"). CD correlated with NSA (linear regression). "Critical type" correlated with female gender and NSA (logistic regression). Discussion: More than half of the humerus are "critical types" as to SAHN and may, therefore, be at risk for procedure-related complications.

The Reverse Shoulder Arthroplasty Angle in MRI: Impact of the Articular Cartilage in the Estimated Inclination of the Inferior Glenoid.

Purpose: To describe the reverse shoulder arthroplasty angle (RSA angle) in magnetic resonance imaging (MRI) and compare the angle formed using bony landmarks (Bony RSA angle or B-RSA angle) with another angle formed using the cartilage margin as reference (Cartilage RSA angle or C-RSA angle). Methods: Adult patients with a shoulder MRI obtained in our hospital between July 2020 and July 2021 were included. The C-RSA angle and B-RSA angle were measured. All images were independently assessed by 4 evaluators. Intraclass correlation coefficient (ICC) was determined for the B-RSA and C-RSA to evaluate interobserver agreement. Results: A total of 61 patients were included with a median age of 59 years (17-77). C-RSA angle was significantly higher than B-RSA (25.4° ± 0.7 vs 19.5° ± 0.7, respectively) with a P-value <.001. The overall agreement was considered "good" for C-RSA (ICC = 0.74 [95% CI 0.61-0.83]) and "excellent" for B-RSA angle (ICC = 0.76 [95% CI 0.65-0.85]). Conclusions: C-RSA angle is significantly higher than B-RSA angle. In cases without significant glenoid wear neglecting to account for the remaining articular cartilage at the inferior glenoid margin may result in superior inclination of standard surgical guides.

Prior bariatric surgery is associated with an increased rate of complications after primary shoulder arthroplasty independent of body mass index.

BACKGROUND: Bariatric surgery (BS) is a debated, yet commonly used, management strategy in the treatment of morbidly obese patients. Despite recent advances in BS techniques, there is limited data on the potential impact of prior BS in patients undergoing shoulder arthroplasty. This investigation evaluated the outcomes of primary shoulder arthroplasty (SA) in patients with prior BS when compared to matched controls. METHODS: Over a 31-year period (1989-2020), 183 primary SA (12 hemiarthroplasties [HAs], 59 anatomic total shoulder arthroplasties [aTSAs], and 112 reverse shoulder arthroplasties [RSAs]) in patients with prior BS and a minimum of 2-year follow-up had been performed at a single institution. This cohort was matched 1:1:1 according to age, sex, diagnosis, implant, American Society of Anesthesiologists score, Charlson Comorbidity Index, and SA surgical year to separate control groups of SA with no history of BS and a BMI of either <40 (low BMI group) or ≥40(high BMI group). Surgical complications, medical complications, reoperations, revisions, and implant survivorship were assessed. The mean follow-up time was 6.8 years (range, 2-21 years). RESULTS: The bariatric surgery cohort had a higher rate of any complication (29.5% vs. 14.8% vs. 14.2%; P < .001), surgical complications (25.1% vs. 12.6% vs. 12.6%; P = .002), and noninfectious complications (20.2% vs. 10.4% vs. 9.8%; low P = .009 and high P = .005) relative to both low and high BMI groups. For BS patients, the 15-year survivorship free of any complication was 55.6 (95% confidence interval [CI], 43.8%-70.5%) compared with 80.3% (95% CI, 72.3%-89.3%) in the low BMI group and 75.8% (65.6%-87.7%) in the high BMI group (P < .001). Comparisons of the bariatric and matched groups demonstrated no statistical differences between the risk of reoperation or revision surgery. When SA was performed within 2 years of BS, higher rates of complications (50% vs. 27.0%; P = .030), reoperations (35.0% vs. 8.0%; P = .002), and revisions (30.0% vs. 5.5%; P = .002) were observed. CONCLUSIONS: Primary shoulder arthroplasty in patients with prior bariatric surgery demonstrated an elevated complication profile when compared to matched cohorts of patients with no history of BS and either low or high BMI. These risks were more pronounced when shoulder arthroplasty was performed within 2 years of bariatric surgery. Care teams should be aware of the potential implications of the postbariatric metabolic state and investigate whether further perioperative optimization is warranted.

Establishing safe zones to avoid nerve injury in the posterior minimally invasive plate osteosynthesis for humerus fractures: a magnetic resonance imaging study.

Background: Safety zones to avoid nerve injury at proximal incision of posterior minimally invasive plate osteosynthesis for humerus fracture have been scarcely studied. The purpose of this study was to describe the location of axillary and radial nerves (RN) in magnetic resonance imaging to establish safety zones. Methods: Fifty-two magnetic resonance imaging studies of the entire humerus were reviewed. The mean age was 50.6 ± 12.1 years, with 37 female patients. The distance of the axillary nerve (AN; distal portion, humeral midpoint) and RN (medial border, midpoint, and lateral border of the humerus) was measured in relation to the posterolateral acromion angle, acromioclavicular axis, and transepicondylar axis. Univariate analysis (Student's t test) and a multivariate analysis (linear regression) were performed. P values < .05 were considered significant. Results: The AN location at the humerus was 54.9 ± 6.4 mm (20.1% humeral length [HL]) in relation to posterolateral acromion angle and 63.2 ± 6.1 mm (23.2% HL) in relation to acromioclavicular axis. The RN location was 100.2 ± 17.1 mm (36.6% HL) at the humerus medial border, 118.0 ± 21.5 mm (43.1% HL) at the humerus midpoint, and 146.0 ± 24.4 mm (53.6% HL) at the humerus lateral border. In relation to transepicondylar axis, it was 175.4 ± 15.6 mm (64.3% HL), 156.0 ± 19.0 mm (57.2% HL), and 127.4 ± 21.2 mm (46.7% HL), respectively. Nerves location was related to HL, independent of gender. Conclusion: The main finding of our study is that the location of the AN and RN in relation to the humerus is related to the HL and can be used to predictably define the safe zones to avoid nerve injury in the proximal incision of posterior minimally invasive plate osteosynthesis for humerus fractures.

Critical shoulder angle and failure of conservative treatment in patients with atraumatic full thickness rotator cuff tears.

BACKGROUND: Atraumatic full thickness rotator cuff tears (AFTRCT) are common lesions whose incidence increases with age. Physical therapy is an effective conservative treatment in these patients with a reported success rate near 85% within 12 weeks of treatment. The critical shoulder angle (CSA) is a radiographic metric that relates the glenoid inclination with the lateral extension of the acromion in the coronal plane. A larger CSA has been associated with higher incidence of AFTRCT and a higher re-tear rate after surgical treatment. However, no study has yet described an association between a larger CSA and failure of conservatory treatment in ARCT. The main objective of this study is to determine whether there is an association between CSA and failure of physical therapy in patients with AFTRCT. METHODS: We reviewed the imaging and clinical records of 48 patients (53 shoulders), 60% female, with a mean age of 63.2 years (95% CI ± 10.4 years); treated for AFTRCT who also underwent a true anteroposterior radiograph of the shoulder within a year of diagnosis of the tear. We recorded demographic (age, sex, type of work), clinical (comorbidities), and imaging data (CSA, size and location of the tear). We divided the patients into two groups according to success or failure of conservative treatment (indication for surgery), so 21 shoulders (39.6%) required surgery and were classified as failure of conservative treatment. Univariate and multivariate analysis was performed to detect predictors of failure of conservative treatment. RESULTS: The median CSA was 35.5º with no differences between those with failure (median 35.5º, range 29º to 48.2º) and success of conservative treatment (median 35.45º, range 30.2º to 40.3º), p = 0.978. The multivariate analysis showed a younger age in patients with failure of conservative treatment (56.14 ± 9.2 vs 67.8 ± 8.4, p < 0.001) and that male gender was also associated with failure of conservative treatment (57% of men required surgery vs 28% of women, p = 0.035). CONCLUSIONS: It is still unclear if CSA does predict failure of conservative treatment. A lower age and male gender both could predicted failure of conservative treatment in AFTRCT. Further research is needed to better address this subject.

Increasing incidence of rotator cuff surgery: A nationwide registry study in Chile.

BACKGROUND: The rotator cuff surgery (RCS) incidence is rising rapidly in North America, Europe, Asia, and Australia. Despite this, multiple factors limit patients' access to surgery. In Latin America, barriers to orthopedic surgery have been largely ignored. The purpose of this study was to calculate the rate of RCS in Chile between 2008 and 2018, investigating possible associated factors to access such as age, sex, and the health insurance. METHODS: An ecological study was carried out with nationwide data obtained from the Database of Hospital Discharges of the Department of Statistics. All Chilean inhabitants aged 25 years or more were included. We used the ICD-10 codes M751, M754, and S460. The annual incidence rate of surgeries and the incidence rate for the period studied per 100,000 inhabitants were calculated. Data were analyzed stratified by age, sex, year of study, and the health insurance. Negative binomial regression was used to compare rates. Statistical analyzes were performed with Stata v.14 software. RESULTS: 39,366 RCSs were performed, with a total rate for the period of 32.36 per 100,000 inhabitants. The annual rate of surgeries from 2008 to 2018 increased from 24.55 to 49.11 per 100,000/year. When adjusting for year, an annual increase in surgery rates of 8.19% (95% CI 6.7-9.6) and 101% growth between 2008 and 2018 (95% CI 90-109%, p < 0.001) was observed. When comparing the global rates according to the health insurance, the public system corresponds to 21.3 per 100,000 and the private system to 72 per 100,000, the latter being 3.4-times higher (95% CI 2.7-4.4; p < 0.001). CONCLUSION: RCS rates are increasing in Chile concordantly with previous reports of other western countries. The most important factor associated with RCS rate found was the patients' health insurance, with higher rates observed for the private sector.

Distal clavicle fractures with "superior intact cortical bone": minimally invasive surgery.

Introduction: Distal clavicle fractures represent 12%-26% of all clavicle fractures. For unstable cases, surgical fixation is the preferred method of treatment. To date, there is still controversy regarding the best fixation method with a high reoperation and complication rate reported. The purpose of this article is to describe a minimally invasive method for reduction and stabilization of displaced distal clavicle fractures, using cortical buttons. Surgical technique: After standard preoperative preparation, a 3-cm incision is made at the coracoclavicular area. Using both coracoid and clavicle tunnels, fracture reduction and fixation is obtained using a cortical fixation button. Standard postoperative care is given. Results: A total of 21 patients (19 men) with a mean age of 34.7 years were treated using this technique. The follow-up was between 6 and 41 months, with an average of 23.4 months. The mean simple shoulder test score was 79.4 (range 66-91.7), and the QuickDASH score was 11 (range 6.8-15.9). Consolidation of the fracture was confirmed at the 12-week follow-up radiography, with no cases of nonunion or malunion identified. No patients presented infection or complications at the surgical site. Implant removal was not needed in this series. All the patients returned to work. Conclusion: Minimally invasive button fixation of unstable distal clavicle fractures is a safe and reliable alternative treatment. The initial outcome report is promising with excellent clinical and radiological results and no complications or implant removals.