High Irritation and Removal Rates After Plate or Nail Fixation in Patients With Displaced Midshaft Clavicle Fractures

Background: Studies comparing plate with intramedullary nail fixation of displaced midshaft clavicle fractures show faster recovery in the plate group and implant-related complications in both groups after short-term followup (6 or 12 months). Knowledge of disability, complications, and removal rates beyond the first postoperative year will help surgeons in making a decision regarding optimal implant choice. However, comparative studies with followup beyond the first year or two are scarce. Questions/purposes: We asked: (1) Does plate fixation or intramedullary nail fixation for displaced midshaft clavicle fractures result in less disability? (2) Which type of fixation, plate or intramedullary, is more frequently associated with implant-related irritation and implant removal? (3) Is plate or intramedullary fixation associated with postoperative complications beyond the first postoperative year? Methods: Between January 2011 and August 2012, patients with displaced midshaft clavicle fractures were enrolled and randomized to plate or intramedullary nail fixation. A total of 58 patients with plate and 62 patients with intramedullary nails initially were enrolled. Minimum followup was 30 months (mean, 39 months; range, 30–51 months). Two patients (3%) with plate fixation and two patients (3%) with intramedullary nails were lost to followup. The Qui

Operative treatment of dislocated midshaft clavicular fractures: Plate or intramedullary nail fixation?: A randomized controlled trial

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End cap versus no end cap in intramedullary nailing for displaced midshaft clavicle fractures : influence on implant-related irritation

Purpose: Implant-related irritation at the entry site is a known disadvantage of intramedullary nailing for clavicle fractures. The purpose of this study was to compare implant-related irritation rates of intramedullary nailing with or without an end cap for displaced midshaft clavicle fractures. Methods: Two cohorts of patients treated with intramedullary nailing with or without an end cap were matched and compared. Primary outcome was patient-reported implant-related irritation. Secondary outcome parameters were complications. Results: A total of 34 patients with an end cap were matched with 68 patients without an end cap. There was no difference in implant-related irritation (41 versus 53%, P = 0.26). Significantly more minor revisions were observed in the group without an end cap (15 versus 0%, P = 0.03). For complications requiring major revision surgery, significantly more implant failures were observed in the end cap group (12 versus 2%, P = 0.04). Regardless of their treatment, patients with complex fractures (AO/OTA B2–B3) reported significantly more medial irritation compared to patients with simple fractures (AO/OTA B1)(P = 0.02). Conclusion: The use of an end cap after intramedullary nailing for displaced midshaft clavicle fractures did not result in lower patient-reported irritation rates. Although less minor revisions were observed, more major revisions were reported in the end cap group. Based on the results of this study, no end caps should be used after intramedullary nailing for displaced midshaft clavicle fractures. However, careful selection of simple fractures might be effective in reducing implant-related problems after intramedullary nailing

Treatment of thoracic or lumbar burst fractures with Balloon Assisted Endplate Reduction using Tricalcium Phosphate cement: histological and radiological evaluation

Abstract Background Short-segment pedicle-screw instrumentation is frequently used to stabilize thoracolumbar burst fractures. A recognized disadvantage of this procedure is recurrent kyphosis from intervertebral disc creep into the fractured central endplate. Balloon Assisted Endplate Reduction (BAER) using Tricalcium Phosphate bone cement (TCP) enables elevation of the centrally depressed endplate. Our objective was to evaluate the bone-tissue response to TCP and to analyse whether BAER using TCP can prevent recurrent kyphosis after removal of the instrumentation. Methods Fourteen patients with traumatic thoracolumbar burst fractures were operated with BAER using TCP in combination with short-segment instrumentation. Nine months after surgery, instrumentation was removed and transpedicular biopsies were taken for histological and histochemical analysis. Roentgenograms pre- and postoperatively and at latest follow-up after removal of the instrumentation were evaluated. Results Average follow-up was 2.6 years. Analysis of the biopsies showed a variable degree of bone remodelling with incorporation of TCP into newly formed bone matrix. No extensive foreign body reactions, inflammation, granulomatous responses or tissue necrosis were observed. Wedge-angle, kyphosis-angle and both the anterior-posterior and central-posterior vertebral body height ratios improved significant postoperatively (p < 0.001). After removal of the instrumentation no significant differences in wedge-angle or height ratios were seen (p = 0.12). The kyphosis-angle increased four degrees (p = 0.01). Conclusion TCP showed good histological osseointegration with no adverse events. TCP can therefore be safely used and could be beneficial in treatment of thoracolumbar burst fractures. BAER with TCP in combination with short-segment instrumentation might reduce recurrence of deformity even after removal of the instrumentation in comparison to short-segment instrumentation alone. Trial registration This study is registered at the at the Dutch Trial Registry (NTR3498)

Anteroinferior versus superior plating of clavicular fractures

Background: Open reduction and plate fixation has gained recognition as an effective treatment for certain types of clavicular fractures. However, 88% of cases report some implant-related problems. To determine the optimal plate position, the aim of the present study was to compare implant-related irritation and proportion of plate removal in patients with clavicular fractures undergoing plate fixation by an anteroinferior or superior approach. Methods: Retrospectively collected data of 39 patients who underwent anteroinferior plating for displaced midshaft clavicular fractures were compared with prospectively collected data of 60 patients who were treated with superior plate fixation as part of a multicenter randomized controlled trial. Electronic medical records were reviewed for reports of complications, in particular, implant-related irritation and implant removal during follow-up. In addition, all patients were contacted in June 2014 to obtain additional information. The primary outcome parameter was implant-related irritation. Results: Univariate and multivariate regression analysis showed plate position was not significantly associated with implant-related irritation. Higher rates of asymptomatic patients with the plate still in place were observed in the anteroinferior group (46% vs 22%, P = .01). Almost an equal percentage of implant removals was seen in both groups because of implant irritation (36% vs 37%, P = .938). Conclusions: The present study found the surgical approach of clavicular plating was not associated with implant-related irritation. Future studies are needed to determine whether there is an optimal approach for clavicle plating

Treatment of thoracic or lumbar burst fractures with Balloon Assisted Endplate Reduction using Tricalcium Phosphate cement: histological and radiological evaluation

Abstract Background Short-segment pedicle-screw instrumentation is frequently used to stabilize thoracolumbar burst fractures. A recognized disadvantage of this procedure is recurrent kyphosis from intervertebral disc creep into the fractured central endplate. Balloon Assisted Endplate Reduction (BAER) using Tricalcium Phosphate bone cement (TCP) enables elevation of the centrally depressed endplate. Our objective was to evaluate the bone-tissue response to TCP and to analyse whether BAER using TCP can prevent recurrent kyphosis after removal of the instrumentation. Methods Fourteen patients with traumatic thoracolumbar burst fractures were operated with BAER using TCP in combination with short-segment instrumentation. Nine months after surgery, instrumentation was removed and transpedicular biopsies were taken for histological and histochemical analysis. Roentgenograms pre- and postoperatively and at latest follow-up after removal of the instrumentation were evaluated. Results Average follow-up was 2.6 years. Analysis of the biopsies showed a variable degree of bone remodelling with incorporation of TCP into newly formed bone matrix. No extensive foreign body reactions, inflammation, granulomatous responses or tissue necrosis were observed. Wedge-angle, kyphosis-angle and both the anterior-posterior and central-posterior vertebral body height ratios improved significant postoperatively (p < 0.001). After removal of the instrumentation no significant differences in wedge-angle or height ratios were seen (p = 0.12). The kyphosis-angle increased four degrees (p = 0.01). Conclusion TCP showed good histological osseointegration with no adverse events. TCP can therefore be safely used and could be beneficial in treatment of thoracolumbar burst fractures. BAER with TCP in combination with short-segment instrumentation might reduce recurrence of deformity even after removal of the instrumentation in comparison to short-segment instrumentation alone. Trial registration This study is registered at the at the Dutch Trial Registry (NTR3498)

Surgical fixation of midshaft clavicle fractures : A systematic review of biomechanical studies

Purpose: Surgical treatment of displaced midshaft clavicle fractures requires a decision between plate fixation and intramedullary (IM) fixation. Numerous studies report on the biomechanical properties of various repair constructs. The goal of this systematic review was to provide an overview of studies describing the biomechanical properties of the most commonly used surgical fixations of midshaft clavicle fractures. Additionally, we aimed to translate these biomechanical results into clinically relevant conclusions. Methods: A computer-aided search of the EMBASE and PudMed/MEDLINE databases was conducted. Studies included for review compared biomechanical properties of plate fixation with IM fixation and superiorly positioned plates with anteroinferiorly positioned plates for midshaft clavicle fractures. Results: Fifteen studies were eligible for inclusion. Plate fixation seemed to form a more robust construct than IM fixation in terms of stiffness and failure loading. The remaining clavicle was stronger after removal of the IM device than after removal of the plate. Superior plating of transverse fractures generally seemed to provide greater stiffness and strength during bending loads than anteroinferior plating did. The absence of cortical alignment in wedge and comminuted fractures directly influenced the fixation stability for both IM fixation and plate fixation, regardless of location. Conclusion: Each type of fracture fixation has biomechanical advantages and disadvantages. However, exact thresholds of stiffness for inducing healing and failure strength to withstand refractures are unknown. The clinical relevance of the biomechanical studies may be arguable. Since none of the studies investigate the effect of tissue adaptation over time they should be interpreted with caution

Surgical fixation of midshaft clavicle fractures: A systematic review of biomechanical studies

Purpose: Surgical treatment of displaced midshaft clavicle fractures requires a decision between plate fixation and intramedullary (IM) fixation. Numerous studies report on the biomechanical properties of various repair constructs. The goal of this systematic review was to provide an overview of studies describing the biomechanical properties of the most commonly used surgical fixations of midshaft clavicle fractures. Additionally, we aimed to translate these biomechanical results into clinically relevant conclusions. Methods: A computer-aided search of the EMBASE and PudMed/MEDLINE databases was conducted. Studies included for review compared biomechanical properties of plate fixation with IM fixation and superiorly positioned plates with anteroinferiorly positioned plates for midshaft clavicle fractures. Results: Fifteen studies were eligible for inclusion. Plate fixation seemed to form a more robust construct than IM fixation in terms of stiffness and failure loading. The remaining clavicle was stronger after removal of the IM device than after removal of the plate. Superior plating of transverse fractures generally seemed to provide greater stiffness and strength during bending loads than anteroinferior plating did. The absence of cortical alignment in wedge and comminuted fractures directly influenced the fixation stability for both IM fixation and plate fixation, regardless of location. Conclusion: Each type of fracture fixation has biomechanical advantages and disadvantages. However, exact thresholds of stiffness for inducing healing and failure strength to withstand refractures are unknown. The clinical relevance of the biomechanical studies may be arguable. Since none of the studies investigate the effect of tissue adaptation over time they should be interpreted with caution

High Irritation and Removal Rates After Plate or Nail Fixation in Patients With Displaced Midshaft Clavicle Fractures

Background: Studies comparing plate with intramedullary nail fixation of displaced midshaft clavicle fractures show faster recovery in the plate group and implant-related complications in both groups after short-term followup (6 or 12 months). Knowledge of disability, complications, and removal rates beyond the first postoperative year will help surgeons in making a decision regarding optimal implant choice. However, comparative studies with followup beyond the first year or two are scarce. Questions/purposes: We asked: (1) Does plate fixation or intramedullary nail fixation for displaced midshaft clavicle fractures result in less disability? (2) Which type of fixation, plate or intramedullary, is more frequently associated with implant-related irritation and implant removal? (3) Is plate or intramedullary fixation associated with postoperative complications beyond the first postoperative year? Methods: Between January 2011 and August 2012, patients with displaced midshaft clavicle fractures were enrolled and randomized to plate or intramedullary nail fixation. A total of 58 patients with plate and 62 patients with intramedullary nails initially were enrolled. Minimum followup was 30 months (mean, 39 months; range, 30–51 months). Two patients (3%) with plate fixation and two patients (3%) with intramedullary nails were lost to followup. The QuickDASH was obtained at final followup and compared between patients who had plate fixation and those who had intramedullary nail fixation. Postoperative complications measured include infection, implant-related irritation, implant failure, nonunion, and refracture after implant removal. Indications for implant removal included implant-related irritation, implant failure, nonunion, patient’s wish, or surgeon’s preference. Results: Between patients with plate versus intramedullary nail fixation, there were no differences in QuickDASH scores (plate, 1.8 ± 3.6; intramedullary nail, 1.8 ± 7.2; mean difference, −0.7; 95% CI, −2.2 to 2.04; p = 0.95). The proportion of patients having implant-related irritation was not different (39 of 56 [70%] versus 41 of 62 [66%]; relative risk, 1.05; 95% CI, 0.82–1.35; p = 0.683). Intramedullary fixation was associated with a higher likelihood of implant removal (51 of 62 [82%] versus 28 of 56 [50%]; relative risk, 1.65; 95% CI, 1.24–2.19; p < 0.001). Among the removed implants more plates than intramedullary nails were removed after the 1-year followup (12 of 28 [43%] versus six of 51 [12%]; p = 0.002). There were no infections, implant breakage, nonunions, or refractures between the 1-year and final followup in either group. Conclusions: After a mean followup of 39 months, disability scores were excellent. Major complications did not occur after the 1-year followup. A frequent and bothersome problem after both surgical treatments is implant-related irritation, resulting in high rates of implant removal, after 1 year. Future research could focus on analyzing risk factors for implant irritation or removal. Level of Evidence: Level II, therapeutic study