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Acute lateral dislocated clavicular fractures: arthroscopic stabilization with TightRope
J Shoulder Elbow Surg (2014) 23, e47-e52
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Acute lateral dislocated clavicular fractures: arthroscopic stabilization with TightRope Pierorazio Motta, MD*, Laura Bruno, MD, Alberto Maderni, MD, Piermario Tosco, MD, Umberto Mariotti, MD Shoulder Unit, CTO Orthopedic and Trauma Center, Turin, Italy Hypothesis: Type IIA, IIB, and V lateral clavicular fractures (Craig modification of the Neer classification) are characterized by a constant displacement and are associated with a high rate of nonunion. The aim of this study is to verify whether the reduction and arthroscopic stabilization of these clavicular fractures with coracoclavicular cerclage provide stable fixation to allow for bone healing. To date, the treatment of these fractures is still controversial in young active patients in whom functional requirements are to be met. Methods: Fourteen male patients, with type IIA, IIB, and V lateral clavicular fractures (2 type IIA, 10 type IIB, and 2 type V) had been treated arthroscopically with a TightRope (Arthrex, Naples, FL, USA) and had a radiologic/clinical follow-up of at least 2 years. Results: All fractures were confirmed to have healed without limitations in range of motion or loss of reduction. The acromioclavicular joint and the coracoclavicular interspace were restored to the level of the healthy site in all but 1 patient, in whom a reduction was observed because of hypercorrection of the fracture. The mean Constant score was 95, and all patients had a Simple Shoulder Test score of 12 points. Healing was delayed up to 20 days in 1 patient because of a skin infection, and the coracoid bone tunnel was too marginal in another patient, in whom the coracoid button broke the lateral side of the tunnel during fixation. Conclusions: The arthroscopic procedure with the TightRope allows for fracture healing with no loss of reduction in the acromioclavicular joint and full return to everyday activities. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Lateral clavicular fracture; TightRope; arthroscopy; bone healing; acute facture; ACJ stability
It has been estimated that lateral-end clavicular fractures account for 10% to 17% of clavicular fractures.6,18,21 Types IIA, IIB, and type V (Craig modification of the Neer classification6) are characterized by displacement of the fracture (partial [IIB] or complete [IIA/V] continuity of the coracoclavicular ligaments). *Reprint requests: Pierorazio Motta, MD, Shoulder Unit, CTO Orthopedic and Trauma Centre, Via Zuretti 29, 10126 Turin, Italy. E-mail address: [email protected] (P. Motta).
Both instability and displacement are characteristic features of these types of fractures. The trapezius muscle tends to displace the medial clavicular fragment posteriorly and proximally, whereas the displacement of the distal fragment is caused by the distal pull of the weight of the arm and the medial pulling effect of the pectoralis major and minor muscles and the latissimus dorsi. Reduction and healing are further impeded by the interposition of the fibers of the trapezius muscle and its fascia between the fracture fragments.
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2013.05.016
e48 According to Robinson and Cairns,24 11 of 86 conservatively treated patients had a symptomatic nonunion that required surgery. Rokito et al26 reported nonunion in 44% of patients (7 of 16), but only 2 were symptomatic. To date, no guidelines have been established for the treatment of significant displacement of fracture stumps in young active patients with functional requirements. Indeed, open surgical techniques that conserve clavicular mobility have been proposed, for example, extra-articular sling,9,19 flip buttons,4,23 transosseous suture,13 hook plates,28 and clavicular plates.3 Some techniques provide a more rigid fixation of the fracture and may restrict clavicular mobility, such as coracoclavicular screws,1 intramedullary K-wires,12 or Knowles pins.11 More recently, arthroscopic techniques, able to allow for the consolidation of the fracture, have been proposed.2,4,14,19,22 The first aim of this study was verify whether acute arthroscopic treatment with coracoclavicular cerclage is able to maintain the reduction of the fragments so as to allow for bone healing. The second aim was to check for the presence of any associated articular lesions.
Materials and methods A series of 28 consecutive patients was treated prospectively for acute displaced fracture of the lateral clavicle between January 2007 and June 2010; 25 of 28 were treated arthroscopically with a TightRope (Arthrex, Naples, FL, USA). Inclusion criteria were a completely acute traumatic displaced fracture without bone contact, age between 18 and 40 years, and a minimum 2-year follow-up. Exclusion criteria were associated lesions, low functional requirements (ie, no sporting activity, retirement, or no heavy work), and surgery delay greater than 10 days. We excluded 14 patients: 2 patients had humeral head fractures, 1 patient had a Bankart lesion associated with a Hill-Sachs lesion observed and treated during the procedure, 2 patients had low functional requirements, 1 patient was aged younger than 18 years, 2 patients were aged older than 40 years, and the surgical procedure was delayed in 2 patients. Another patient had a new injury, that is, a midclavicular fracture on the same side on which, 3 years earlier, he had been treated for a Neer type IIB fracture. This did not affect the previous repair, and the new fracture was treated conservatively. Finally, 3 patients declined surgery and were treated nonoperatively; all had nonunion with pain during heavy duties but still did not require any surgery at the 2-year follow-up. Of the 28 patients, 14 were enrolled in the study. All the patients were men, with a mean age of 32 5.8 years (range, 1840 years), and had lateral-end clavicular fractures: 12 had type IIA/IIB lesions, and 2 had type V lesions. All patients were right handed, and the lesion was on the dominant side in 6 of 14 patients and on the nondominant side in 8. Clinical data were evaluated by an independent observer (P.T.) at 3, 6, 12, and 24 months postoperatively. The clinical evaluation was based on the Constant score and Simple Shoulder Test, and acromioclavicular joint stability on the horizontal and vertical planes was evaluated by the cross-arm test and manual dislocation.16 The time lapse between surgery and the patient resuming
P. Motta et al.
Figure 1 Standard radiograph: consolidation without loss of reduction at 2 years (arrows). preinjury activity was also taken into consideration. Radiographic union was evaluated by an anteroposterior view, supplemented by angled (Zanca30), axillary, and stress views (Fig. 1). Radiographs were evaluated by an independent observer (L.B.) who was not a member of the surgical team at 1 and 3 months postoperatively, with a minimum 2-year follow-up. Radiologic consolidation was defined as the presence of cortical bridging between the proximal and distal fragments in 2 different projections (secondary bone healing). Clinical consolidation was determined by the absence of pain when the clavicle and shoulder were mobilized. The reduction was considered anatomic if the difference between the lower margin of the medial and lateral fragments was at most 2 mm on the Zanca projection. The space between the lower edge of the clavicle and the upper margin of the coracoid was compared with the healthy contralateral side in the standing position and under stress.
Surgical technique The arthroscopic procedure was performed with an interscalene nerve block with the patient in the beach-chair position, without traction, under fluoroscopic guidance. The mean surgery time was 60 11.3 minutes (range, 45-90 minutes). Three portals were used: a posterior portal and an anterolateral portal for the optical device and an operative anterosuperior portal. The posterior portal was used to explore the glenohumeral articular cavity. The anterolateral portal (in proximity to the anterior margin of the acromion) was used to explore the lateral and upper surface of the coracoid, whereas the anterosuperior portal was used to introduce a radiofrequency device to expose the lateral and inferior coracoid side. A 4-mm dedicated C-ring drill guide was introduced into the anterosuperior portal and under the coracoid knee. Two percutaneous needles were used to detect the anterior and posterior clavicle edge on the same plane of the base of the coracoid. In this area, a 10-mm skin incision was made. The guidewire was directed from the posterior site of the clavicle to the coracoid base as close as possible to the coracoid center. Then, a cannulated drill pin was introduced through the clavicle (not less than 10 mm from the medial fracture fragment) and the base of the coracoid. The oblong button was drawn through the skin incision into the clavicle and the coracoid process by pulling the traction suture from the anterosuperior portal. It was then flipped under arthroscopic control, the fracture reduction was fluoroscopically controlled, and the sutures were tightened on the circular clavicular button. A 6-mm clavicular button was used in 2 of 14 patients and a 10-mm button (available only starting in 2008) in 12 of 14. The skin and deltotrapezial fascia incision was made slightly longer (40 mm) in 4 patients who had type IIA fractures to remove muscle interposition. In 1 patient, the coracoid bone tunnel was too marginal and the oblong coracoid button broke the lateral side of the tunnel during
Acute lateral dislocated clavicular fractures
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Figure 3 Figure 2
Clavicular bone resorption at circular button site.
Axillary radiograph: no anterior clavicle dislocation.
fixation, so the TightRope had to be arthroscopically removed. The FiberWire (Arthrex) was cut away from the clavicular incision and the circular button removed. The oblong button was removed with a grasper through the anterosuperior portal. A further hole was made more medially in the coracoid to obtain good bone fixation with a new TightRope. Bone healing was achieved without sequelae in the same timeframe as the other patients. All patients were discharged the day after surgery. Postoperative pain evaluation was carried out with the visual analog scale (VAS) from day 1 to day 7. Postoperative care involved the use of a shoulder sling (UltraSling; DJO, Vista, CA, USA) for 4 weeks; immediate elbow and hand movements were allowed. Passive shoulder motion started at 4 weeks (elevation <90 ), with full active motion at 6 weeks. No contact sports were permitted until 3 months postoperatively.
Figure 4 Standard radiograph: circular button englobed into clavicle and with no reduction, loss, or increase in coracoclavicular interspace.
the clavicle without contact with the coracoid in another 2 patients. Control radiographs at follow-up showed a visible clavicular bone tunnel in all cases.
Clinical outcome
Results Of the patients, 10 had IIB type, 2 had type IIA, and 2 had type V lateral clavicular fractures.
Radiologic outcome All fractures showed clinical and radiologic healing at 1 month postoperatively. The difference between the lower margin of the medial and lateral fragments was anatomic on the Zanca projection in 13 of 14 patients, whereas 1 patient had a difference of 3 mm. The axillary projection did not show any anterior clavicular dislocation (Fig. 2). There was superior clavicle cortical bone resorption at the button site in all patients, with no loss of fracture reduction or alteration in the coracoclavicular space (Fig. 3). Two patients had migration of the clavicular button, which was englobed into the clavicle (1 had a 6-mm button and the other had a 10-mm button), with no loss of reduction (Fig. 4). There was ossification in continuity with the inferior margin of
The mean Constant score was 95 0.73 (range, 94-96), and all patients had a Simple Shoulder Test score of 12 points. No differences were evidenced in range of motion or acromioclavicular joint stability between the operated shoulder and the healthy side on clinical examination at the 2-year follow-up. Return to pre-trauma everyday activities took a mean of 3 months, and previous sporting activities were resumed at 6 months. Complications with suture knots on the clavicular side were not observed.
Complications In 1 of 4 patients who had a type IIA fracture with muscle interposition, wound infection developed; it resolved with oral antibiotics within 20 days without sequelae. The mean VAS score at 2 weeks after surgery was 2 0.61 (range, 1-3).
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Discussion The results of this study confirm that reduction and arthroscopic stabilization of these clavicular fractures with the TightRope provide stable fixation to allow for bone healing. We are in agreement with Levy13 and Robinson et al,23 who state that the coracoclavicular ligaments and acromioclavicular articular capsule are intact in type IIA and V lesions or partially damaged in type IIB lesions. Therefore, the medial clavicle end had no connection with the coracoclavicular ligaments. These lesions do not require restoration of the continuity of the ligaments; rather, they require holding the proximal clavicle bone fragment in contact with the lateral fragment until bone healing occurs. Indeed, our data suggest that consolidation of the fractures can be achieved without the need for interfragmentary fixation, in contrast to what has been recommended by other authors.13,19 We are aware that there are some limiting factors in this study, such as the small number of cases, the need for a longer follow-up to evaluate any evolution of acromioclavicular arthritis, the lack of a conservatively treated control group, and the lack of radiographic criteria to distinguish between types IIA and IIB. Nonunion rates of 11.5% to 30% for conservatively treated lateral clavicular fractures (type IIA/IIB) have been reported in the literature.18,20 The main negative prognostic factors are age older than 60 years and the entity of the dislocation itself.25 Although various techniques have been proposed for the treatment of the fractured stumps, to date, no clear guidelines for young patients in whom functional requirements are to be met have been reported in the literature. This is most likely because of the low incidence of these types of lesions and, consequently, limited numbers of patients treated. The incidence of complications and nonunions with open surgical techniques varies: 40.7% for hook plate fixation, 20% for K-wire and tension-band fixation, 6.3% for interfragmentary fixation, 4.8% for coracoclavicular fixation, and 2.4% for intramedullary fixation.20 In the literature, authors have reported on numerous arthroscopic techniques that do not preserve the integrity of the rotator interval. Checchia et al4 reported on 7 patients treated with extra-articular fixation (No. 5 FiberWire): all had consolidation with a mean follow-up of 15 months (range, 12-24 months). However, 3 patients had complications: 1 delayed bone healing to 3 months, 1 had a frozen shoulder, and 1 had a skin infection. Nourissat et al19 described a case report in which fixation with 2 sutures (No. 2 FiberWire) was proposed: one suture was passed through a hole inside the coracoid knee and on top of the proximal part of the clavicle, and the other was passed around the fracture. Pujol et al22 reported on 4 patients with a mean age of 35 years (range, 24-45 years): all achieved bone healing and were evaluated at a mean follow-up of 6 months.
P. Motta et al. We are in agreement with Baumgarten,2 who reported that the coracoid knee should not be reached through the articular rotator cuff interval but should be reached through an anterolateral portal for vision and an anterosuperior working portal to expose the lateral and inferior portion of the coracoid. In disagreement with Robinson et al,23 we are of the opinion that the arthroscopic preparation of the coracoid, exposed from its base to the conjoined tendon, offers a better view of the bone tunnel than does an open surgical technique. The width of the coracoid (mean, 13.9 mm)27 may pose a surgical difficulty when making a bone tunnel of 4 mm in patients with slight builds. There are only 2 reports in the literature on secondary coracoid fracture associated with the TightRope. Bindra et al3 reported on a 32-year-old man who underwent arthroscopically assisted grade 3 acute reduction of the acromioclavicular joint with the TightRope and an allograft. Eight weeks later, while he was doing weightlifting, the implant failed because of a fracture of the coracoid with recurrent dislocation of the acromioclavicular joint. In this patient, the fracture could have been caused by erosion of the graft around the base of the coracoid, as reported in the literature.10,15,29 Gerhardt et al8 reported on a 57-year-old woman who had a resection of the lateral portion of the clavicle and arthroscopically assisted reduction with a Graftrope (Arthrex), 2 months after a grade 5 acromioclavicular joint dislocation. At a visit 1 week after surgery, this patient had a loss of reduction because of a coracoid fracture. In this case, the hole in the coracoid was 6 mm and not 4 mm as in the TightRope, and according to Ferreira et al,7 the hole must be made in the center of the base of the coracoid. Transclavicular-transcoracoid 6-mm-diameter drilling appears to be a significant risk of coracoid fractures.5 To reduce the risk, we started drilling the guidewire from the posterior clavicular side to the coracoid’s center, along the most favorable trajectory. A 4-mm bone tunnel was made instead of a 6-mm tunnel. To our knowledge, this is the first time that clavicle cortical bone resorption at the button site has been reported, although it has been described in acromioclavicular dislocation treatment.17 In 2 patients, the circular clavicular button migrated into the center of the clavicle, without loss of reduction or variation in the coracoclavicular interspace compared with the healthy side. This finding differed from our experience in acromioclavicular dislocation, in which it is common to observe a partial reduction loss. No correlations were observed between the outcome and the dimensions of the clavicular button, the persistence of the clavicular bone tunnel, or the presence of ossification on the inferior surface of the clavicle. The data from our study suggest that arthroscopic techniques also allow for the diagnosis of any intra-articular lesions and their treatment, permitting a better evaluation of long-term outcomes based on associated pathologies. Arthroscopic treatment offers several other advantages: it yields better esthetic results; it
Acute lateral dislocated clavicular fractures can be carried out with the patient under regional anesthesia; there is no need to open the fracture site, nor is a second surgical sitting required for the removal of hardware; and it provides good postoperative pain control (the mean day 1 postoperative VAS score was 2).
Conclusions The first aim of the study was confirmed: The arthroscopic procedure with the TightRope allows for fracture healing with no loss of reduction in the acromioclavicular joint. The second aim was also confirmed: Associated Bankart and Hill-Sachs lesions were found in 1 patient. The described arthroscopic technique allows a rapid functional recovery in young active patients and full return to everyday activities at the same level as before the injury. Moreover, there is no need for a second operation to remove the devices. The arthroscopic procedure allows for the selection of patients who have only a lateral clavicular fracture without associated intra-articular lesions. The arthroscopic procedure, interscalene nerve block, reduction in postoperative pain, and day-hospital treatment offered an excellent allaround satisfaction ratio. Although no neurovascular lesions were observed in this series, we recommend limiting this procedure to surgeons with arthroscopic expertise, and we welcome further studies to confirm our preliminary findings.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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e51 5. Coale RM, Hollister SJ, Dines JS, Allen AA, Bedi A. Anatomic considerations of transclavicular-transcoracoid drilling for coracoclavicular ligament reconstruction. J Shoulder Elbow Surg 2013; 22:137-44. http://dx.doi.org/10.1016/j.jse.2011.12.008 6. Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Matsen FA III, editors. The shoulder, Volume 1. Philadelphia: WB Saunders; 1990. p. 367-401. 7. Ferreira JV, Chowaniec D, Obopilwe E, Nowak MD, Arciero RA, Mazzocca AD. Biomechanical evaluation of effect of coracoid tunnel placement on load to failure of fixation during repair of acromioclavicular joint dislocations. Arthroscopy 2012;28:1230-6. http://dx.doi. org/10.1016/j.arthro.2012.02.004 8. Gerhardt DC, VanDerWerf JD, Rylander LS, McCarty EC. Postoperative coracoid fracture after transcoracoid acromioclavicular joint reconstruction. J Shoulder Elbow Surg 2011;20:e6-10. http://dx.doi. org/10.1016/j.jse.2011.01.017 9. Goldberg JA, Bruce WJ, Sonnabend DH, Walsh WR. Type 2 fractures of the distal clavicle: a new surgical technique. J Shoulder Elbow Surg 1997;6:380-2. 10. Jeon IH, Dewnany G, Hartley R, Neumann L, Wallace WA. Chronic acromioclavicular separation: the medium term results of coracoclavicular ligament reconstruction using braided polyester prosthetic ligament. Injury 2007;38:1247-53. http://dx.doi.org/10.1016/j. injury.2007.05.019 11. Jou IM, Chiang EP, Lin CJ, Lin CL, Wang PH, Su WR. Treatment of unstable distal clavicle fractures with Knowles pin. J Shoulder Elbow Surg 2011;20:414-9. http://dx.doi.org/10.1016/j.jse.2010.08.009 12. Kona J, Bosse MJ, Staeheli JW, Rosseau RL. Type II distal clavicle fractures: a retrospective review of surgical treatment. J Orthop Trauma 1990;4:115-20. 13. Levy O. Simple, minimally invasive surgical technique for treatment of type 2 fractures of the distal clavicle. J Shoulder Elbow Surg 2003; 12:24-8. http://dx.doi.org/10.1067/mse.2003.128564 14. Lu MT, Glaser DL, Huffman GR. Arthroscopically assisted fixation of unstable distal third clavicle fractures. Available at: http://upoj.org/ site/files/v21/v21_12.pdf. U Penn Orthop J 2011;21:36-40. 15. Moneim MS, Balduini FC. Coracoid fracture as a complication of surgical treatment by coracoclavicular tape fixation. A case report. Clin Orthop Relat Res 1982:133-5. 16. Motta P, Bruno L, Maderni A, Tosco P, Mariotti U. Acromioclavicular motion after surgical reconstruction. Knee Surg Sports Traumatol Arthrosc 2012;20:1012-8. http://dx.doi.org/10.1007/s00167-011-1627-5 17. Murena L, Vulcano E, Ratti L, Cecconello A, Rolla PR, Surace MF. Arthroscopic treatment of acute acromioclavicular dislocation with double flip button. Knee Surg Sports Traumatol Arthrosc 2009;17: 1511-5. http://dx.doi.org/10.1007/s00167-009-0838-5 18. Neer CS. Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma 1963;3:99-110. 19. Nourissat G, Kakuda C, Dumontier C, Sautet A, Doursounian L. Arthroscopic stabilization of Neer type 2 fracture of the distal part of the clavicle. Arthroscopy 2007;23:674.e1-e4. http://dx.doi.org/10. 1016/j.arthro.2006.08.028 20. Oh JH, Kim SH, Lee JH, Shin SH, Gong HS. Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures. Arch Orthop Trauma Surg 2011;131:525-33. http://dx.doi. org/10.1007/s00402-010-1196-y 21. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002;11:452-6. http://dx.doi. org/10.1067/mse.2002.126613 22. Pujol N, Philippeau JM, Richou J, Lespagnol F, Graveleau N, Hardy P. Arthroscopic treatment of distal clavicle fractures: a technical note. Knee Surg Sports Traumatol Arthrosc 2008;16:884-6. http://dx.doi. org/10.1007/s00167-008-0578-y 23. Robinson CM, Akhtar MA, Jenkins PJ, Sharpe T, Ray A, Olabi B. Open reduction and EndoButton fixation of displaced fractures of the lateral end of the clavicle in younger patients. J Bone Joint Surg Br 2010;92:811-6. http://dx.doi.org/10.1302/0301-620X.92B6.23558
e52 24. Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am 2004;86: 778-82. 25. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86:1359-65. 26. Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Cuomo F, Gallagher MA. A comparison of nonoperative and operative treatment of type II distal clavicle fractures. Bull Hosp Jt Dis 2002-2003;61:32-9. 27. Salzmann GM, Paul J, Sandmann GH, Imhoff AB, Sch€ottle PB. The coracoidal insertion of the coracoclavicular ligaments: an anatomic
P. Motta et al. study. Am J Sports Med 2008;36:2392-7. http://dx.doi.org/10.1177/ 0363546508322887 28. Schmittinger K, Sikorski A. Experiences with the Balser plate in dislocations of the acromioclavicular joint and lateral fractures of the clavicle [in German]. Aktuelle Traumatol 1983;13:190-3. 29. Tomlinson D, Altchek D, Davila J, Cordasco F. A modified technique of arthroscopically assisted AC joint reconstruction and preliminary results. Clin Orthop Relat Res 2008;466:639-45. http://dx.doi.org/10. 1007/s11999-007-0085-3 30. Zanca P. Shoulder pain: involvement of the acromioclavicular joint: analysis of 1,000 cases. AJR Am J Roentgenol 1971;112:493-506.
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Acute lateral dislocated clavicular fractures: arthroscopic stabilization with TightRope Pierorazio Motta, MD*, Laura Bruno, MD, Alberto Maderni, MD, Piermario Tosco, MD, Umberto Mariotti, MD Shoulder Unit, CTO Orthopedic and Trauma Center, Turin, Italy Hypothesis: Type IIA, IIB, and V lateral clavicular fractures (Craig modification of the Neer classification) are characterized by a constant displacement and are associated with a high rate of nonunion. The aim of this study is to verify whether the reduction and arthroscopic stabilization of these clavicular fractures with coracoclavicular cerclage provide stable fixation to allow for bone healing. To date, the treatment of these fractures is still controversial in young active patients in whom functional requirements are to be met. Methods: Fourteen male patients, with type IIA, IIB, and V lateral clavicular fractures (2 type IIA, 10 type IIB, and 2 type V) had been treated arthroscopically with a TightRope (Arthrex, Naples, FL, USA) and had a radiologic/clinical follow-up of at least 2 years. Results: All fractures were confirmed to have healed without limitations in range of motion or loss of reduction. The acromioclavicular joint and the coracoclavicular interspace were restored to the level of the healthy site in all but 1 patient, in whom a reduction was observed because of hypercorrection of the fracture. The mean Constant score was 95, and all patients had a Simple Shoulder Test score of 12 points. Healing was delayed up to 20 days in 1 patient because of a skin infection, and the coracoid bone tunnel was too marginal in another patient, in whom the coracoid button broke the lateral side of the tunnel during fixation. Conclusions: The arthroscopic procedure with the TightRope allows for fracture healing with no loss of reduction in the acromioclavicular joint and full return to everyday activities. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Lateral clavicular fracture; TightRope; arthroscopy; bone healing; acute facture; ACJ stability
It has been estimated that lateral-end clavicular fractures account for 10% to 17% of clavicular fractures.6,18,21 Types IIA, IIB, and type V (Craig modification of the Neer classification6) are characterized by displacement of the fracture (partial [IIB] or complete [IIA/V] continuity of the coracoclavicular ligaments). *Reprint requests: Pierorazio Motta, MD, Shoulder Unit, CTO Orthopedic and Trauma Centre, Via Zuretti 29, 10126 Turin, Italy. E-mail address: [email protected] (P. Motta).
Both instability and displacement are characteristic features of these types of fractures. The trapezius muscle tends to displace the medial clavicular fragment posteriorly and proximally, whereas the displacement of the distal fragment is caused by the distal pull of the weight of the arm and the medial pulling effect of the pectoralis major and minor muscles and the latissimus dorsi. Reduction and healing are further impeded by the interposition of the fibers of the trapezius muscle and its fascia between the fracture fragments.
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2013.05.016
e48 According to Robinson and Cairns,24 11 of 86 conservatively treated patients had a symptomatic nonunion that required surgery. Rokito et al26 reported nonunion in 44% of patients (7 of 16), but only 2 were symptomatic. To date, no guidelines have been established for the treatment of significant displacement of fracture stumps in young active patients with functional requirements. Indeed, open surgical techniques that conserve clavicular mobility have been proposed, for example, extra-articular sling,9,19 flip buttons,4,23 transosseous suture,13 hook plates,28 and clavicular plates.3 Some techniques provide a more rigid fixation of the fracture and may restrict clavicular mobility, such as coracoclavicular screws,1 intramedullary K-wires,12 or Knowles pins.11 More recently, arthroscopic techniques, able to allow for the consolidation of the fracture, have been proposed.2,4,14,19,22 The first aim of this study was verify whether acute arthroscopic treatment with coracoclavicular cerclage is able to maintain the reduction of the fragments so as to allow for bone healing. The second aim was to check for the presence of any associated articular lesions.
Materials and methods A series of 28 consecutive patients was treated prospectively for acute displaced fracture of the lateral clavicle between January 2007 and June 2010; 25 of 28 were treated arthroscopically with a TightRope (Arthrex, Naples, FL, USA). Inclusion criteria were a completely acute traumatic displaced fracture without bone contact, age between 18 and 40 years, and a minimum 2-year follow-up. Exclusion criteria were associated lesions, low functional requirements (ie, no sporting activity, retirement, or no heavy work), and surgery delay greater than 10 days. We excluded 14 patients: 2 patients had humeral head fractures, 1 patient had a Bankart lesion associated with a Hill-Sachs lesion observed and treated during the procedure, 2 patients had low functional requirements, 1 patient was aged younger than 18 years, 2 patients were aged older than 40 years, and the surgical procedure was delayed in 2 patients. Another patient had a new injury, that is, a midclavicular fracture on the same side on which, 3 years earlier, he had been treated for a Neer type IIB fracture. This did not affect the previous repair, and the new fracture was treated conservatively. Finally, 3 patients declined surgery and were treated nonoperatively; all had nonunion with pain during heavy duties but still did not require any surgery at the 2-year follow-up. Of the 28 patients, 14 were enrolled in the study. All the patients were men, with a mean age of 32 5.8 years (range, 1840 years), and had lateral-end clavicular fractures: 12 had type IIA/IIB lesions, and 2 had type V lesions. All patients were right handed, and the lesion was on the dominant side in 6 of 14 patients and on the nondominant side in 8. Clinical data were evaluated by an independent observer (P.T.) at 3, 6, 12, and 24 months postoperatively. The clinical evaluation was based on the Constant score and Simple Shoulder Test, and acromioclavicular joint stability on the horizontal and vertical planes was evaluated by the cross-arm test and manual dislocation.16 The time lapse between surgery and the patient resuming
P. Motta et al.
Figure 1 Standard radiograph: consolidation without loss of reduction at 2 years (arrows). preinjury activity was also taken into consideration. Radiographic union was evaluated by an anteroposterior view, supplemented by angled (Zanca30), axillary, and stress views (Fig. 1). Radiographs were evaluated by an independent observer (L.B.) who was not a member of the surgical team at 1 and 3 months postoperatively, with a minimum 2-year follow-up. Radiologic consolidation was defined as the presence of cortical bridging between the proximal and distal fragments in 2 different projections (secondary bone healing). Clinical consolidation was determined by the absence of pain when the clavicle and shoulder were mobilized. The reduction was considered anatomic if the difference between the lower margin of the medial and lateral fragments was at most 2 mm on the Zanca projection. The space between the lower edge of the clavicle and the upper margin of the coracoid was compared with the healthy contralateral side in the standing position and under stress.
Surgical technique The arthroscopic procedure was performed with an interscalene nerve block with the patient in the beach-chair position, without traction, under fluoroscopic guidance. The mean surgery time was 60 11.3 minutes (range, 45-90 minutes). Three portals were used: a posterior portal and an anterolateral portal for the optical device and an operative anterosuperior portal. The posterior portal was used to explore the glenohumeral articular cavity. The anterolateral portal (in proximity to the anterior margin of the acromion) was used to explore the lateral and upper surface of the coracoid, whereas the anterosuperior portal was used to introduce a radiofrequency device to expose the lateral and inferior coracoid side. A 4-mm dedicated C-ring drill guide was introduced into the anterosuperior portal and under the coracoid knee. Two percutaneous needles were used to detect the anterior and posterior clavicle edge on the same plane of the base of the coracoid. In this area, a 10-mm skin incision was made. The guidewire was directed from the posterior site of the clavicle to the coracoid base as close as possible to the coracoid center. Then, a cannulated drill pin was introduced through the clavicle (not less than 10 mm from the medial fracture fragment) and the base of the coracoid. The oblong button was drawn through the skin incision into the clavicle and the coracoid process by pulling the traction suture from the anterosuperior portal. It was then flipped under arthroscopic control, the fracture reduction was fluoroscopically controlled, and the sutures were tightened on the circular clavicular button. A 6-mm clavicular button was used in 2 of 14 patients and a 10-mm button (available only starting in 2008) in 12 of 14. The skin and deltotrapezial fascia incision was made slightly longer (40 mm) in 4 patients who had type IIA fractures to remove muscle interposition. In 1 patient, the coracoid bone tunnel was too marginal and the oblong coracoid button broke the lateral side of the tunnel during
Acute lateral dislocated clavicular fractures
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Figure 3 Figure 2
Clavicular bone resorption at circular button site.
Axillary radiograph: no anterior clavicle dislocation.
fixation, so the TightRope had to be arthroscopically removed. The FiberWire (Arthrex) was cut away from the clavicular incision and the circular button removed. The oblong button was removed with a grasper through the anterosuperior portal. A further hole was made more medially in the coracoid to obtain good bone fixation with a new TightRope. Bone healing was achieved without sequelae in the same timeframe as the other patients. All patients were discharged the day after surgery. Postoperative pain evaluation was carried out with the visual analog scale (VAS) from day 1 to day 7. Postoperative care involved the use of a shoulder sling (UltraSling; DJO, Vista, CA, USA) for 4 weeks; immediate elbow and hand movements were allowed. Passive shoulder motion started at 4 weeks (elevation <90 ), with full active motion at 6 weeks. No contact sports were permitted until 3 months postoperatively.
Figure 4 Standard radiograph: circular button englobed into clavicle and with no reduction, loss, or increase in coracoclavicular interspace.
the clavicle without contact with the coracoid in another 2 patients. Control radiographs at follow-up showed a visible clavicular bone tunnel in all cases.
Clinical outcome
Results Of the patients, 10 had IIB type, 2 had type IIA, and 2 had type V lateral clavicular fractures.
Radiologic outcome All fractures showed clinical and radiologic healing at 1 month postoperatively. The difference between the lower margin of the medial and lateral fragments was anatomic on the Zanca projection in 13 of 14 patients, whereas 1 patient had a difference of 3 mm. The axillary projection did not show any anterior clavicular dislocation (Fig. 2). There was superior clavicle cortical bone resorption at the button site in all patients, with no loss of fracture reduction or alteration in the coracoclavicular space (Fig. 3). Two patients had migration of the clavicular button, which was englobed into the clavicle (1 had a 6-mm button and the other had a 10-mm button), with no loss of reduction (Fig. 4). There was ossification in continuity with the inferior margin of
The mean Constant score was 95 0.73 (range, 94-96), and all patients had a Simple Shoulder Test score of 12 points. No differences were evidenced in range of motion or acromioclavicular joint stability between the operated shoulder and the healthy side on clinical examination at the 2-year follow-up. Return to pre-trauma everyday activities took a mean of 3 months, and previous sporting activities were resumed at 6 months. Complications with suture knots on the clavicular side were not observed.
Complications In 1 of 4 patients who had a type IIA fracture with muscle interposition, wound infection developed; it resolved with oral antibiotics within 20 days without sequelae. The mean VAS score at 2 weeks after surgery was 2 0.61 (range, 1-3).
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Discussion The results of this study confirm that reduction and arthroscopic stabilization of these clavicular fractures with the TightRope provide stable fixation to allow for bone healing. We are in agreement with Levy13 and Robinson et al,23 who state that the coracoclavicular ligaments and acromioclavicular articular capsule are intact in type IIA and V lesions or partially damaged in type IIB lesions. Therefore, the medial clavicle end had no connection with the coracoclavicular ligaments. These lesions do not require restoration of the continuity of the ligaments; rather, they require holding the proximal clavicle bone fragment in contact with the lateral fragment until bone healing occurs. Indeed, our data suggest that consolidation of the fractures can be achieved without the need for interfragmentary fixation, in contrast to what has been recommended by other authors.13,19 We are aware that there are some limiting factors in this study, such as the small number of cases, the need for a longer follow-up to evaluate any evolution of acromioclavicular arthritis, the lack of a conservatively treated control group, and the lack of radiographic criteria to distinguish between types IIA and IIB. Nonunion rates of 11.5% to 30% for conservatively treated lateral clavicular fractures (type IIA/IIB) have been reported in the literature.18,20 The main negative prognostic factors are age older than 60 years and the entity of the dislocation itself.25 Although various techniques have been proposed for the treatment of the fractured stumps, to date, no clear guidelines for young patients in whom functional requirements are to be met have been reported in the literature. This is most likely because of the low incidence of these types of lesions and, consequently, limited numbers of patients treated. The incidence of complications and nonunions with open surgical techniques varies: 40.7% for hook plate fixation, 20% for K-wire and tension-band fixation, 6.3% for interfragmentary fixation, 4.8% for coracoclavicular fixation, and 2.4% for intramedullary fixation.20 In the literature, authors have reported on numerous arthroscopic techniques that do not preserve the integrity of the rotator interval. Checchia et al4 reported on 7 patients treated with extra-articular fixation (No. 5 FiberWire): all had consolidation with a mean follow-up of 15 months (range, 12-24 months). However, 3 patients had complications: 1 delayed bone healing to 3 months, 1 had a frozen shoulder, and 1 had a skin infection. Nourissat et al19 described a case report in which fixation with 2 sutures (No. 2 FiberWire) was proposed: one suture was passed through a hole inside the coracoid knee and on top of the proximal part of the clavicle, and the other was passed around the fracture. Pujol et al22 reported on 4 patients with a mean age of 35 years (range, 24-45 years): all achieved bone healing and were evaluated at a mean follow-up of 6 months.
P. Motta et al. We are in agreement with Baumgarten,2 who reported that the coracoid knee should not be reached through the articular rotator cuff interval but should be reached through an anterolateral portal for vision and an anterosuperior working portal to expose the lateral and inferior portion of the coracoid. In disagreement with Robinson et al,23 we are of the opinion that the arthroscopic preparation of the coracoid, exposed from its base to the conjoined tendon, offers a better view of the bone tunnel than does an open surgical technique. The width of the coracoid (mean, 13.9 mm)27 may pose a surgical difficulty when making a bone tunnel of 4 mm in patients with slight builds. There are only 2 reports in the literature on secondary coracoid fracture associated with the TightRope. Bindra et al3 reported on a 32-year-old man who underwent arthroscopically assisted grade 3 acute reduction of the acromioclavicular joint with the TightRope and an allograft. Eight weeks later, while he was doing weightlifting, the implant failed because of a fracture of the coracoid with recurrent dislocation of the acromioclavicular joint. In this patient, the fracture could have been caused by erosion of the graft around the base of the coracoid, as reported in the literature.10,15,29 Gerhardt et al8 reported on a 57-year-old woman who had a resection of the lateral portion of the clavicle and arthroscopically assisted reduction with a Graftrope (Arthrex), 2 months after a grade 5 acromioclavicular joint dislocation. At a visit 1 week after surgery, this patient had a loss of reduction because of a coracoid fracture. In this case, the hole in the coracoid was 6 mm and not 4 mm as in the TightRope, and according to Ferreira et al,7 the hole must be made in the center of the base of the coracoid. Transclavicular-transcoracoid 6-mm-diameter drilling appears to be a significant risk of coracoid fractures.5 To reduce the risk, we started drilling the guidewire from the posterior clavicular side to the coracoid’s center, along the most favorable trajectory. A 4-mm bone tunnel was made instead of a 6-mm tunnel. To our knowledge, this is the first time that clavicle cortical bone resorption at the button site has been reported, although it has been described in acromioclavicular dislocation treatment.17 In 2 patients, the circular clavicular button migrated into the center of the clavicle, without loss of reduction or variation in the coracoclavicular interspace compared with the healthy side. This finding differed from our experience in acromioclavicular dislocation, in which it is common to observe a partial reduction loss. No correlations were observed between the outcome and the dimensions of the clavicular button, the persistence of the clavicular bone tunnel, or the presence of ossification on the inferior surface of the clavicle. The data from our study suggest that arthroscopic techniques also allow for the diagnosis of any intra-articular lesions and their treatment, permitting a better evaluation of long-term outcomes based on associated pathologies. Arthroscopic treatment offers several other advantages: it yields better esthetic results; it
Acute lateral dislocated clavicular fractures can be carried out with the patient under regional anesthesia; there is no need to open the fracture site, nor is a second surgical sitting required for the removal of hardware; and it provides good postoperative pain control (the mean day 1 postoperative VAS score was 2).
Conclusions The first aim of the study was confirmed: The arthroscopic procedure with the TightRope allows for fracture healing with no loss of reduction in the acromioclavicular joint. The second aim was also confirmed: Associated Bankart and Hill-Sachs lesions were found in 1 patient. The described arthroscopic technique allows a rapid functional recovery in young active patients and full return to everyday activities at the same level as before the injury. Moreover, there is no need for a second operation to remove the devices. The arthroscopic procedure allows for the selection of patients who have only a lateral clavicular fracture without associated intra-articular lesions. The arthroscopic procedure, interscalene nerve block, reduction in postoperative pain, and day-hospital treatment offered an excellent allaround satisfaction ratio. Although no neurovascular lesions were observed in this series, we recommend limiting this procedure to surgeons with arthroscopic expertise, and we welcome further studies to confirm our preliminary findings.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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