Elastic Stable Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures-A Randomized, Controlled, Clinical Trial

From the Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Innsbruck, Austria.
Journal of orthopaedic trauma (Impact Factor: 1.8). 03/2009; 23(2):106-12. DOI: 10.1097/BOT.0b013e318190cf88
Source: PubMed


To compare elastic stable intramedullary nailing (ESIN) with nonoperative treatment of fully displaced midshaft clavicular fractures in adults.
The study was a randomized, controlled, clinical trial.
Level 1 trauma center.
Sixty patients between 18 and 65 years of age participated and completed the study. They were randomized to either operative or nonoperative treatment with a 2-year follow-up.
Thirty patients were treated with a simple shoulder sling and 30 patients with ESIN within 3 days after trauma.
Complications after operative and nonoperative treatments, Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score for outcome measurement, and clavicular shortening.
Fracture union was achieved in all patients in the operative group, whereas nonunion was observed in 3 of 30 patients of the nonoperative group. Two symptomatic malunions required corrective osteotomy in the nonoperative group. Medial nail protrusion occurred in 7 cases in the operative group. Implant failure with revision surgery was necessary in 2 patients after an additional adequate trauma. DASH scores were lower in the operative group throughout the first 6 months and 2 years after trauma, with a significant difference during the first 18 weeks. Constant scores were significantly higher after 6 months and 2 years after intramedullary stabilization. Patients in the operative group showed a significant improvement of posttraumatic clavicular shortening; they were also more satisfied with cosmetic appearance and overall outcome.
ESIN of displaced midshaft clavicular fractures resulted in a lower rate of nonunion and delayed union, a faster return to daily activities, and a better functional outcome. Clavicular shortening was significantly lower, and overall satisfaction was higher in the operative group.

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    • "Injury patterns were classified according to OTA/AO (Orthopaedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen) classification [[20]]. Based on reported clavicle union rates at 10 to 16 weeks following operative fixation [[3],[7],[12],[21]], a nonunion was defined as a painful, persistent fracture line with no radiographic progression of healing over three consecutive months with or without fixation failure which required surgical revision. A malunion was defined as a fracture that achieved a malpositioned bony union stable from the initial reduction and fixation or a reduction that changed with time. "
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    ABSTRACT: Background The purpose of this study was to evaluate surgical healing rates, implant failure, implant removal, and the need for surgical revision with regards to plate type in midshaft clavicle fractures fixed with 2.7-mm anteroinferior plates utilizing modern plating techniques.Methods This retrospective exploratory cohort review took place at a level I teaching trauma center and a single large private practice office. A total of 155 skeletally mature individuals with 156 midshaft clavicle fractures between March 2002 and March 2012 were included in the final results. Fractures were identified by mechanism of injury and classified based on OTA/AO criteria. All fractures were fixed with 2.7-mm anteroinferior plates. Primary outcome measurements included implant failure, malunion, nonunion, and implant removal. Secondary outcome measurements included pain with the visual analog scale and range of motion. Statistically significant testing was set at 0.05, and testing was performed using chi-square, Fisher¿s exact, Mann¿Whitney U, and Kruskall-Wallis.ResultsImplant failure occurred more often in reconstruction plates as compared to dynamic compression plates (p¿=¿0.029). Malunions and nonunions occurred more often in fractures fixed with reconstruction plates as compared to dynamic compression plates, but it was not statistically significant. Implant removal attributed to irritation or implant prominence was observed in 14 patients. Statistically significant levels of pain were seen in patients requiring implant removal (p¿=¿0.001) but were not associated with the plate type.Conclusions Anteroinferior clavicular fracture fixation with 2.7-mm dynamic compression plates results in excellent healing rates with low removal rates in accordance with the published literature. Given higher rates of failure, 2.7-mm reconstruction plates should be discouraged in comparison to stiffer and more reliable 2.7-mm dynamic compression plates.
    Journal of Orthopaedic Surgery and Research 07/2014; 9(1):55. DOI:10.1186/s13018-014-0055-x · 1.39 Impact Factor
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    • "Many reports point out higher rates of complications – such as shortening, nonunion, deformity, and unsatisfactory patientderived outcomes – in cases of adult displaced mid-shaft clavicle fractures.7-14 Two recent randomized controlled studies have demonstrated superior results in favour of the operative treatment in those cases of completely displaced clavicle fractures in the adult population.15,16 Definitive indications for internal fixation of closed clavicle fractures in adult patients are still debatable. "
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    ABSTRACT: The literature available on patient-orientated outcomes of operative management for clavicle fractures in adolescents is fairly limited. Open surgical treatment of displaced midshaft fractures of the clavicle continues to be a topic of controversy. Traditional treatment of clavicle fractures has been via non-operative methods in both children and adults. Management in adolescent patients remains controversial, and rightly so, as the traditional experience from non-operative methods has been regarded as satisfactory, while the literature on the more recent approach towards fixing some of these fractures is evolving. We present a review of relevant literature.
    Orthopedic Reviews 07/2013; 5(3):e29. DOI:10.4081/or.2013.e29
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    • "If open fracture reduction is necessary, surgical incisions are in general smaller in comparison to plate fixation resulting in improved cosmetic results. In addition, smaller incisions may result in lower infection rates [6, 11]. Possible disadvantages of ESIN are medial nail protrusion and the need for implant removal requiring a second operation [11, 12]. "
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    ABSTRACT: The incidence of operative treatment of dislocated midshaft clavicle fractures (DMCF) is rising due to unsatisfactory results after non-operative treatment. Knowledge of complications is important for selection of the surgical technique and preoperative patient counselling. The aim of this study is to compare complications after plate fixation and elastic stable intramedullary nailing (ESIN) with a titanium elastic nail (TEN) for DMCF. A retrospective analysis of our surgical database was performed. From January 2005 to January 2010, 90 patients with DMCF were treated with plate fixation or ESIN. Complications were evaluated in both treatment groups and subsequently compared. Seven implant failures occurred in six patients (14 %) of the plate group and one implant failure (2.1 %) was seen in the ESIN group (p = 0.051). Major revision surgery was performed in five cases in the plate group (11.6 %) and in one case (2.1 %) in the ESIN group (p = 0.100). Three refractures (7.0 %) were observed in the plate group after removal of the implant against none in the ESIN group (p = 0.105). Six minor revisions (13 %) were reported in the ESIN group and none were reported in the plate group (p = 0.027). Compared to other studies we report higher rates of refracture (7.0 %), major revision surgery (11.6 %) and implant failure (14.0 %) after plate fixation. The frequency of implant failures differed almost significantly for patients treated with plate fixation compared to ESIN. Furthermore, a tendency towards refracture after implant removal and major revision surgery after plate fixation was observed.
    International Orthopaedics 07/2012; 36(10):2139-45. DOI:10.1007/s00264-012-1615-5 · 2.11 Impact Factor
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