Is the Supraclavicular Approach Effective in Treating Patients with Thoracic Outlet Syndrome?

Thoracic outlet syndrome is a challenging clinical condition in terms of diagnosis, treatment, and health-related quality of life assessment. In this review, the authors provide a description of the clinical approach, surgical management, and longitudinal follow-up for patients with neurogenic, venous, and arterial thoracic outlet syndrome. The review represents the experiences of a high-volume, dedicated thoracic outlet syndrome program, where patients are treated in a multidisciplinary team and operative decompression occurs through primarily a supraclavicular approach. Data supporting the safety and efficacy of this approach are provided, as are clinical care considerations for surgeons treating patients with thoracic outlet syndrome.

Missed Medial Clavicular Physeal Fracture-Posterior Dislocation Complicated by Brachiocephalic Pseudoaneurysm: A Case Report.

CASE: We present a 17-year-old male patient with an initially missed posterior sternoclavicular fracture dislocation who presented with symptoms related to thrombotic emboli arising from a pseudoaneurysm. He was treated 6 weeks after injury with a figure-of-eight tendon allograft repair with good clinical outcomes. CONCLUSION: This is a unique presentation that highlights the significant risk of a missed diagnosis, life-threatening complications that may ensue, and biomechanically superior surgical intervention.

The therapeutic value of ipsilateral supraclavicular lymphadenectomy in locally advanced breast cancer: A review.

The treatment of isolated ipsilateral supraclavicular lymph node metastasis for locally advanced breast cancer has always been a controversial issue for breast surgeons. However, with the further understanding of the metastasis and treatment of breast cancer, it is now considered to be a locally advanced disease, and there is a new debate on the treatment of isolated ipsilateral supraclavicular lymph node metastasis. The author reviewed the relevant literature and briefly discussed the clinical significance of supraclavicular lymph node resection in patients with locally advanced breast cancer presenting with isolated ipsilateral supraclavicular lymph node metastasis.

[Treatment of clavicle fracture: Interpretation of the 2023 American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines].

Clavicle fracture is a common orthopedic injury, accounting for approximately 2.6%-4% of all adult skeletal fractures. In 2023, the American Academy of Orthopaedic Surgeons (AAOS) developed evidence-based treatment guidelines for clavicle fractures, which include 4 recommendations and 10 options. This article, based on a thorough review of the guidelines, discusses the clinical treatment of clavicle fractures, aiming to share advancements and the latest diagnostic and therapeutic considerations with orthopedic colleagues to enhance treatment outcomes.

[Effectiveness of minimally invasive internal fixation with locking plates for mid-shaft clavicle fractures].

Objective: To explore effectiveness of minimally invasive internal fixation with locking plates for mid-shaft clavicle fractures. Methods: Between October 2022 and August 2023, 28 patients with mid-shaft clavicle fractures were treated by minimally invasive internal fixation with locking plates. There were 10 males and 18 females with a mean age of 46.2 years (range, 18-74 years). The fractures were caused by traffic accident in 16 patients, sports-related injury in 7 patients, and other injuries in 5 patients. According to Robinson classification, the fractures were classified as type 2A1 in 1 case, type 2A2 in 6 cases, type 2B1 in 15 cases, and type 2B2 in 6 cases. The interval between fracture and operation ranged from 5 hours to 21 days (median, 1.0 days). The pain visual analogue scale (VAS) score was 8.1±1.6. The VAS score at 3 days after operation and the occurrence of complications after operation were recorded. During follow-up, X-ray films were re-examined to observe the healing of the fracture; the shoulder joint function was evaluated according to the Constant-Murley score at 6 months, and the length of the incision scar (total length of the distal and proximal incisions) was measured. Results: All operations were successfully completed without any subclavian vascular or nerve damage. All incisions healed by first intention. The VAS score was 1.2±0.7 at 3 days after operation, and there was a significant difference in VAS score between pre- and post-operation ( t=8.704， P<0.001). At 1 week after operation, the patient's shoulder was basically painless, and they resumed normal life. All patients were followed up 12-20 months (mean, 13.3 months). X-ray films showed that the bone callus began to form at 2-4 months after operation (mean, 2.7 months). There was no delayed healing or non healing of the fracture, and no loosening or fracture of the internal fixators during follow-up. At 6 months after operation, the mean total incision length was 1.5 cm (range, 1.1-1.8 cm); no patient complained of numbness or paresthesia on subclavicular region or anterior chest wall. The Constant-Murley score of shoulder joint function was 93-100 (mean, 97.6). Conclusion: Minimally invasive internal fixation with locking plates is a good surgical method for treating mid-shaft clavicle fractures, with simple operation, minimal trauma, good postoperative results, and high satisfaction.

Comparing the clinical features of lateral and medial approaches of costoclavicular technique versus traditional lateral sagittal technique as infraclavicular brachial plexus block methods: a randomized controlled trial.

BACKGROUND: It is aimed to compare the block onset times and performance features of costoclavicular techniques (medial and lateral approach) versus lateral sagittal technique. METHODS: Patients were randomized into three groups. For costoclavicular techniques, ultrasound probe was placed parallel to clavicle obtaining nerve cords, axillary artery and axillary vein visual from lateral-to-medial, respectively. The block needle was advanced from lateral (Group CLB) or medial (Group CMB) to perform costoclavicular block. For lateral sagittal technique (Group LSB), ultrasound probe was placed sagittal and perpendicular below the coracoid process to obtain sagittal artery image with the cords around. Total 20 ml of 0.5% bupivacaine and 10 ml of 2% lidocaine were deposited for all groups. Sensory and motor block onset times, block performance properties, complications, and patient/surgeon satisfactions were investigated. RESULTS: Among 56 patients, the primary outcome, sensory block onset time was shorter in Group CLB than Group CMB and Group LSB (10 [5-15], 10 [10-20], and 15 [10-15] minutes, respectively, p < 0.05). Motor block onset was also fastest in Group CLB (15 [10-20] mins for CLB, 20 [15-20] mins for LSB, and 22.5 [15-25] mins for CMB, p = 0.004). Block performance properties did not differ between the groups. The only complication observed was vascular puncture with an incidence of 28% in Group CMB. CONCLUSIONS: Lateral approach costoclavicular technique provides fastest block onset than the other techniques. Considering the success and safety profile, this technique stands as a good alternative in clinical practice. TRIAL REGISTRATION: This study is prospectively registered to clinicaltrials.gov on 20/02/2022 (NCT05260736).

[Hyoid epiglottis combined with sternocleidomastoid muscle clavicle flap for repairing laryngeal defect after laryngeal trauma infection: a case report].

The initial treatment of open laryngeal trauma must be implemented immediately, with the primary focus on saving lives. However, in the later stages, various factors may cause changes in the structure and function of the larynx, which requires special attention. This article reports on the treatment process of a patient with depression who suffered from laryngeal trauma. Due to the late stage of laryngeal infection causing laryngeal defects, a hyoid epiglottis combined with sternocleidomastoid muscle clavicular flap repair was performed. Additionally, personalized functional exercise was performed, ultimately resulting in recovery.

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.

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).

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.

Enhancing semantic segmentation in chest X-ray images through image preprocessing: ps-KDE for pixel-wise substitution by kernel density estimation.

BACKGROUND: In medical imaging, the integration of deep-learning-based semantic segmentation algorithms with preprocessing techniques can reduce the need for human annotation and advance disease classification. Among established preprocessing techniques, Contrast Limited Adaptive Histogram Equalization (CLAHE) has demonstrated efficacy in improving segmentation algorithms across various modalities, such as X-rays and CT. However, there remains a demand for improved contrast enhancement methods considering the heterogeneity of datasets and the various contrasts across different anatomic structures. METHOD: This study proposes a novel preprocessing technique, ps-KDE, to investigate its impact on deep learning algorithms to segment major organs in posterior-anterior chest X-rays. Ps-KDE augments image contrast by substituting pixel values based on their normalized frequency across all images. We evaluate our approach on a U-Net architecture with ResNet34 backbone pre-trained on ImageNet. Five separate models are trained to segment the heart, left lung, right lung, left clavicle, and right clavicle. RESULTS: The model trained to segment the left lung using ps-KDE achieved a Dice score of 0.780 (SD = 0.13), while that of trained on CLAHE achieved a Dice score of 0.717 (SD = 0.19), p<0.01. ps-KDE also appears to be more robust as CLAHE-based models misclassified right lungs in select test images for the left lung model. The algorithm for performing ps-KDE is available at https://github.com/wyc79/ps-KDE. DISCUSSION: Our results suggest that ps-KDE offers advantages over current preprocessing techniques when segmenting certain lung regions. This could be beneficial in subsequent analyses such as disease classification and risk stratification.

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.

The Role of Botulinum Neurotoxin A in the Conservative Treatment of Fractures: An Experimental Study on Rats.

This paper explores the role of botulinum neurotoxin in aiding fracture recovery through temporary muscle paralysis. Specifically, it investigates the effects of botulinum neurotoxin-induced paralysis of the sternocleidomastoid muscle on clavicle fractures in rats. The research aims to assess safety, effectiveness, and the impact on fracture healing. Healthy male Albino Wistar rats were divided into four groups: clavicle fracture, botulinum neurotoxin injection, both, and control. Surgeries were conducted under anaesthesia, and postoperatively, animals were monitored for 28 days. Euthanasia and radiological assessment followed, examining fracture healing and muscle changes, while tissues were histopathologically evaluated. The modified Lane-Sandhu scoring system was used for the radiographic evaluation of clavicle fractures, and the results varied from complete healing to nonunion. Histopathological examination at 28 days postfracture showed fibrous tissue, mesenchymal cells, and primary callus formation in all groups. Despite varied callus compositions, botulinum neurotoxin administration did not affect clavicle healing, as evidenced by similar scores to the control group. Several studies have explored botulinum neurotoxin applications in fracture recovery. Research suggests its potential to enhance functional recovery in certain types of fractures. Theoretical benefits include managing muscle spasticity, aiding reduction techniques, and preventing nonunion. However, botulinum neurotoxin's transient effect and nonuniversal applications should be considered. The present study found that botulinum toxin had no clear superiority in healing compared to controls, while histological evaluation showed potential adverse effects on muscle tissue. Further research is essential to understand its risk-benefit balance and long-term effects.

No code machine learning: validating the approach on use-case for classifying clavicle fractures.

PURPOSE: We created an infrastructure for no code machine learning (NML) platform for non-programming physicians to create NML model. We tested the platform by creating an NML model for classifying radiographs for the presence and absence of clavicle fractures. METHODS: Our IRB-approved retrospective study included 4135 clavicle radiographs from 2039 patients (mean age 52 ± 20 years, F:M 1022:1017) from 13 hospitals. Each patient had two-view clavicle radiographs with axial and anterior-posterior projections. The positive radiographs had either displaced or non-displaced clavicle fractures. We configured the NML platform to automatically retrieve the eligible exams using the series' unique identification from the hospital virtual network archive via web access to DICOM Objects. The platform trained a model until the validation loss plateaus. Once the testing was complete, the platform provided the receiver operating characteristics curve and confusion matrix for estimating sensitivity, specificity, and accuracy. RESULTS: The NML platform successfully retrieved 3917 radiographs (3917/4135, 94.7 %) and parsed them for creating a ML classifier with 2151 radiographs in the training, 100 radiographs for validation, and 1666 radiographs in testing datasets (772 radiographs with clavicle fracture, 894 without clavicle fracture). The network identified clavicle fracture with 90 % sensitivity, 87 % specificity, and 88 % accuracy with AUC of 0.95 (confidence interval 0.94-0.96). CONCLUSION: A NML platform can help physicians create and test machine learning models from multicenter imaging datasets such as the one in our study for classifying radiographs based on the presence of clavicle fracture.