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Reconstruction plate fixation with bone graft for mid-shaft clavicular non-union in semi-professional athletes
JS.Orthop Scial.: (1999) 4:269–272 plating of clavicular non-union in athletes Wentz et Reconstruction
269
Reconstruction plate fixation with bone graft for mid-shaft clavicular non-union in semi-professional athletes Siegfried Wentz, Christian Eberhardt, and Thomas Leonhard Department of Orthopaedic Surgery ‘Friedrichsheim’, Johann Wolfgang Goethe University, Marienburgstraße 2, 60528 Frankfurt/M., Germany
Abstract: From 1993 to 1997, 22 semi-professional athletes (14 men and 8 women), aged 18–33 years (mountain bike racers, soccer players, handball players, swimmers, and short distance runners) with a non-union of the middle third of the clavicle were treated operatively by reconstruction plating and bone grafting. Fourteen clavicular non-unions were caused by falls. Eight non-unions were the result of a car, motorcycle, or bicycle accident. There were 19 atrophic and 3 hypertrophic non-unions. In all patients, initially a figure-ofeight strap or a sling was used for immobilization and no radiographic union was documented within 5 months. None of the athletes had gone back to their sports and all had pain and limitation of shoulder function. For open reduction and internal fixation, an AO 3.5-mm seven-hole reconstruction plate was used. The sclerotic bone ends were freshened and a cortical bone transplant or cancellous bone from the iliac crest (depending on the shortening of the clavicle) was packed around the fracture or between the reduced fracture ends. In all athletes, radiographic consolidation was achieved after an average of 14 weeks (range, 11–16 weeks) and the average increase in the Constant and Murley Score was from 79 points preoperatively to 97 points after surgery. No operative or postoperative complications occured and all athletes returned to their sports. Key words: sports injury, clavicular non-union, reconstruction plating
Introduction The incidence of clavicular fractures appears to be increasing because of a number of factors, including the
Offprint requests to: S. Wentz Received for publication on June 8, 1998; accepted on Dec. 10, 1998
occurrence of more vehicular injuries and the increase in popularity of sports. Mid-shaft clavicle fractures are common, accounting for 80% of clavicular fractures.16,19 Non-union following a fracture of the clavicle is uncommon and is reported in only 0.9%–4% of these fractures.6,7,9,11,14,15,19 However, several factors predispose to non-union: inadequate immobilization, severity of trauma, and degree of displacement, especially with soft tissue or muscle interposition. Pseudarthrosis of the clavicle can cause many problems: pain, neurological and vascular symptoms, loss of shoulder function, cosmetic disfigurement due to shortening of the shoulder girdle, or pseudotumor. In particular, sportspeople with a high activity level, such as semi-professional athletes, will not accept even a mild loss of shoulder function, and they ask for operative treatment.
Subjects and methods Twenty-two athletes with pseudarthrosis of the midthird clavicle were treated operatively with AO reconstruction plating and bone grafting at the Department of Orthopaedic Surgery at Frankfurt University between 1993 and 1997. Fourteen athletes were men and 8 were women. The average age was 24 years (range, 18– 33 years). Nineteen non-unions were atrophic and 3 were hypertrophic. On average the initial trauma had taken place 10 months (range, 5–13 months) prior to surgery. Initially a sling or a figure-of-eight strap2 was used for immobilization in 19 patients, while the remaining patients had not been immobilized because of other severe injuries. Preoperatively, all athletes had pain at the site of pseudarthrosis; 4 patients complained of mild paresthesia at the ipsilateral forearm and hand and 17 patients showed a limitation of shoulder motion, especially abduction and external rotation. On preoperative evaluation with the Constant and Murley Score,5 the shoulder function averaged 79.4 points.
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S. Wentz et al.: Reconstruction plating of clavicular non-union in athletes
During the operation the patient was placed in the beach-chair position. A skin incision of 7–9 cm was made along the inferior border of the clavicle. Atrophic non-unions with shortening of more than 2 cm after reduction and debridement received a cortical bone transplant between the reduced fracture ends. An AO 3.5-mm seven-hole reconstruction plate was used with three screws at each side of the non-union for the internal fixation. Modelling and fitting with the AO reconstruction plate was superior to use of a dynamic compression plate. In patients with atrophic pseudarthrosis without functional shortening of the clavicle, we used cancellous bone from the iliac crest placed at the site of non-union. In a hypertrophic pseudarthrosis, excess bone was removed and cancellous bone was packed into and along the non-union after debridement. Postoperatively the patients were immobilized in a shoulder brace for 6 weeks, especially at night. For this period a controlled gentle activity range of motion, of up to 60 degrees elevation and abduction was allowed. Radiographic follow-up was done postoperatively, at 6, 12, and 18 weeks. The average length of follow-up was 12 months (range, 9–14 months). Results In all 22 surgeries for non-union of the clavicle, the result was successful. The average increase in the Constant and Murley Score5 was from 79.4 points (range,
64–87 points) preoperatively to 97.4 points (range, 91– 100 points) after removal of the plate (Table 1). The average time from surgery to radiographic consolidation in our series was 14 weeks (range, 11–16 weeks) and the average duration until removal of the reconstruction plate was 9 months (range, 7–13 months). The follow-up examinations were scheduled 4 months after removal of the plate (range, 3–7 months). There was one refracture, in a soccer player 3 weeks after removal of the plate, caused by a fall in a soccer match. No intra- or postoperative complications occurred and the average hospital stay was 7 days for open reduction and 4 days for removal of the hardware. Case report A 22-year-old mountain bike racer sustained a displaced mid-shaft fracture of the left clavicle during a bicycle accident. The initial treatment consisted of a figure-of-eight strap. After 5 months, the fracture showed no signs of union and the patient complained of pain with all overhead activities. Radiographs revealed a widely displaced mid-shaft non-union of the left clavicle (Fig. 1). We used the seven-hole AO 3.5-mm reconstruction plate for internal fixation, which was shaped to the anatomy of the clavicle and fitted with three screws at each side of the non-union for stability. After debridement of the decorticated bone ends, cancellous bone was packed into the bony gap (Fig. 2). Radiographic follow-up at 12 weeks showed radiol-
Table 1. Results: Constant and Murley (Card M) score (n 5 22) C and M score5
No pain (15 points)
Full power (25 points)
Full activity of daily living (20 points)
Full range of motion (40 points)
Total: maximum 100 points
Preoperative Follow-up exam.
8.2 14.6
19.4 23.9
16.1 19.7
35.7 39.2
79.4 points 97.4 points
Fig. 1. Mid-shaft clavicular in a 22-year-old mountain bike racer non-union 5 months after nonoperative treatment
Fig. 2. Open reduction and internal fixation with reconstruction plate
S. Wentz et al.: Reconstruction plating of clavicular non-union in athletes
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Fig. 4. Well curved and reconstructed clavicle after removal of the plate Fig. 3. Radiographic follow-up after 12 weeks showed a united clavicle
References ogic consolidation (Fig. 3). At 27 weeks after internal fixation the hardware was removed and full painless range of motion of the shoulder was demonstrated (Fig. 4).
Discussion Several opportunities for the operative treatment of clavicular non-union have been described: intramedullary pinning with Steinmann or Knowles pins, Kirschner wires, fixation with wire sutures or interfragmentary screws, and the use of different plates.1,3,4,6–22 Most of these techniques have shown a number of problems. Intramedullary pins do not provide rigid fixation or adequately control rotational forces in the middle third of the clavicle, and it is difficult to insert the pins correctly in this double-curved bone. Fixation with interfragmentary screws or wire sutures shows insufficient immobilization. Thus, many authors prefer internal fixation with compression plating and additional bone grafting with autogenous iliac bone.7,10,11,13,19 We also prefer plating and bone grafting, but use an AO reconstruction plate (regular or titanium), because this plate can be bent easily to the contour of the clavicle. The plate is placed superiorly on the bone and three screws at each side of the non-union give sufficient rigidity. We know that the indications for internal fixation of a clavicular non-union are the subject of controversy, but semi-professional athletes, in particular, will not accept even a mild loss of shoulder function. Therefore we believe that open reduction and internal fixation with reconstruction plating and bone grafting is a successful method for the operative treatment of posttraumatic mid-shaft clavicular non-union.
1. Albrecht HU, Bamert P. Die Claviculafraktur: Therapie und Komplikationen. Helv Chir, Acta 1981;48:571–83. 2. Bar HW. What is the proper position for the back dressing. Sportverletz Sportschaden 1992;6:182–3. 3. Basom WC, Breck LW, Herz JR. Dual grafts for non-union of the clavicle. South Med J 1947;40:898–9. 4. Boehme D, Curtis RJ, DeHaan JT, et al. Non-unions of the midshaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting. J Bone Joint Surg Am 1991;73:1219–26. 5. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160–4. 6. Domingo-Pech J. El enclavado a compresion de las fracturas de clavicula, con tornillo de esponjosa. Barcelona Quirurgica 1971;15:500–20. 7. Edvardsen P, Odegard O. Treatment of posttraumatic clavicular pseudarthrosis. Acta Orthop Scand 1977;48:456–7. 8. Eskola A, Vainionpää S, Myllynen P. Surgery for ununited clavicular fracture. Acta Orthop Scand 1986;57:366–7. 9. Hansis M, Weller S. Die operative Behandlung der Klavikulapseudarthrose. Operat Orthop Traumatol 1989;3:139–44. 10. Herbsthofer B, Schüz W, Mockwitz J. Indikation zur operativen Behandlung von Klavikulafrakturen. Aktuel Traumatol 1994;24: 263–8. 11. Jupiter JB, Leffert RD. Non-union of the clavicle. Associated complications and surgical management. J Bone Joint Surg Am 1987;69:753–60. 12. Koch F, Papadimitriou G, Groher G. Die Claviculapseudarthrose: Entstehung und Behandlung. Unfallheilkunde 1971;74:330–7. 13. Lindenmaier HL, Kuner EH, Becker B. Die Osteosynthese der Clavikula. Chirurg 1991;62:409–13. 14. Manske DJ, Szabo RM. The operative treatment of mid-shaft clavicular non-unions. J Bone Joint Surg Am 1985;67-A:1367– 71. 15. Marsh HO, Hazarian E. Pseudarthrosis of the clavicle. In: Proceedings of the American, British, Canadian, Australian, New Zealand and South African Orthopaedic Associations. J Bone Joint Surg Br 1970;52:793. 16. Neer CS II. Non-union of the clavicle. JAMA 1960;172:1006– 11. 17. Neer CS II. Part I: Fractures about the shoulder. In: Fractures in adults. Vol. 1. Rockwood CA Jr, Green DP, editors. 2nd ed. Philadelphia: JB Lippincott, 1984:702–7. 18. Neviaser JS. The treatment of fractures of the clavicle. Surg Clin North Am 1963;43:1555–63.
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S. Wentz et al.: Reconstruction plating of clavicular non-union in athletes
19. Pyper JB. Non-union of fractures of the clavicle. Injury 1978;9: 268–70. 20. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop 1968;58:29–42.
21. Sakellarides H. Pseudarthrosis of the clavicle. A report of twenty cases. J Bone Joint Surg Am 1961;43:130–8. 22. Wilkins RM, Johnston RM. Ununited fractures of the clavicle. J Bone Joint Surg Am 1983;65:773–8.
269
Reconstruction plate fixation with bone graft for mid-shaft clavicular non-union in semi-professional athletes Siegfried Wentz, Christian Eberhardt, and Thomas Leonhard Department of Orthopaedic Surgery ‘Friedrichsheim’, Johann Wolfgang Goethe University, Marienburgstraße 2, 60528 Frankfurt/M., Germany
Abstract: From 1993 to 1997, 22 semi-professional athletes (14 men and 8 women), aged 18–33 years (mountain bike racers, soccer players, handball players, swimmers, and short distance runners) with a non-union of the middle third of the clavicle were treated operatively by reconstruction plating and bone grafting. Fourteen clavicular non-unions were caused by falls. Eight non-unions were the result of a car, motorcycle, or bicycle accident. There were 19 atrophic and 3 hypertrophic non-unions. In all patients, initially a figure-ofeight strap or a sling was used for immobilization and no radiographic union was documented within 5 months. None of the athletes had gone back to their sports and all had pain and limitation of shoulder function. For open reduction and internal fixation, an AO 3.5-mm seven-hole reconstruction plate was used. The sclerotic bone ends were freshened and a cortical bone transplant or cancellous bone from the iliac crest (depending on the shortening of the clavicle) was packed around the fracture or between the reduced fracture ends. In all athletes, radiographic consolidation was achieved after an average of 14 weeks (range, 11–16 weeks) and the average increase in the Constant and Murley Score was from 79 points preoperatively to 97 points after surgery. No operative or postoperative complications occured and all athletes returned to their sports. Key words: sports injury, clavicular non-union, reconstruction plating
Introduction The incidence of clavicular fractures appears to be increasing because of a number of factors, including the
Offprint requests to: S. Wentz Received for publication on June 8, 1998; accepted on Dec. 10, 1998
occurrence of more vehicular injuries and the increase in popularity of sports. Mid-shaft clavicle fractures are common, accounting for 80% of clavicular fractures.16,19 Non-union following a fracture of the clavicle is uncommon and is reported in only 0.9%–4% of these fractures.6,7,9,11,14,15,19 However, several factors predispose to non-union: inadequate immobilization, severity of trauma, and degree of displacement, especially with soft tissue or muscle interposition. Pseudarthrosis of the clavicle can cause many problems: pain, neurological and vascular symptoms, loss of shoulder function, cosmetic disfigurement due to shortening of the shoulder girdle, or pseudotumor. In particular, sportspeople with a high activity level, such as semi-professional athletes, will not accept even a mild loss of shoulder function, and they ask for operative treatment.
Subjects and methods Twenty-two athletes with pseudarthrosis of the midthird clavicle were treated operatively with AO reconstruction plating and bone grafting at the Department of Orthopaedic Surgery at Frankfurt University between 1993 and 1997. Fourteen athletes were men and 8 were women. The average age was 24 years (range, 18– 33 years). Nineteen non-unions were atrophic and 3 were hypertrophic. On average the initial trauma had taken place 10 months (range, 5–13 months) prior to surgery. Initially a sling or a figure-of-eight strap2 was used for immobilization in 19 patients, while the remaining patients had not been immobilized because of other severe injuries. Preoperatively, all athletes had pain at the site of pseudarthrosis; 4 patients complained of mild paresthesia at the ipsilateral forearm and hand and 17 patients showed a limitation of shoulder motion, especially abduction and external rotation. On preoperative evaluation with the Constant and Murley Score,5 the shoulder function averaged 79.4 points.
270
S. Wentz et al.: Reconstruction plating of clavicular non-union in athletes
During the operation the patient was placed in the beach-chair position. A skin incision of 7–9 cm was made along the inferior border of the clavicle. Atrophic non-unions with shortening of more than 2 cm after reduction and debridement received a cortical bone transplant between the reduced fracture ends. An AO 3.5-mm seven-hole reconstruction plate was used with three screws at each side of the non-union for the internal fixation. Modelling and fitting with the AO reconstruction plate was superior to use of a dynamic compression plate. In patients with atrophic pseudarthrosis without functional shortening of the clavicle, we used cancellous bone from the iliac crest placed at the site of non-union. In a hypertrophic pseudarthrosis, excess bone was removed and cancellous bone was packed into and along the non-union after debridement. Postoperatively the patients were immobilized in a shoulder brace for 6 weeks, especially at night. For this period a controlled gentle activity range of motion, of up to 60 degrees elevation and abduction was allowed. Radiographic follow-up was done postoperatively, at 6, 12, and 18 weeks. The average length of follow-up was 12 months (range, 9–14 months). Results In all 22 surgeries for non-union of the clavicle, the result was successful. The average increase in the Constant and Murley Score5 was from 79.4 points (range,
64–87 points) preoperatively to 97.4 points (range, 91– 100 points) after removal of the plate (Table 1). The average time from surgery to radiographic consolidation in our series was 14 weeks (range, 11–16 weeks) and the average duration until removal of the reconstruction plate was 9 months (range, 7–13 months). The follow-up examinations were scheduled 4 months after removal of the plate (range, 3–7 months). There was one refracture, in a soccer player 3 weeks after removal of the plate, caused by a fall in a soccer match. No intra- or postoperative complications occurred and the average hospital stay was 7 days for open reduction and 4 days for removal of the hardware. Case report A 22-year-old mountain bike racer sustained a displaced mid-shaft fracture of the left clavicle during a bicycle accident. The initial treatment consisted of a figure-of-eight strap. After 5 months, the fracture showed no signs of union and the patient complained of pain with all overhead activities. Radiographs revealed a widely displaced mid-shaft non-union of the left clavicle (Fig. 1). We used the seven-hole AO 3.5-mm reconstruction plate for internal fixation, which was shaped to the anatomy of the clavicle and fitted with three screws at each side of the non-union for stability. After debridement of the decorticated bone ends, cancellous bone was packed into the bony gap (Fig. 2). Radiographic follow-up at 12 weeks showed radiol-
Table 1. Results: Constant and Murley (Card M) score (n 5 22) C and M score5
No pain (15 points)
Full power (25 points)
Full activity of daily living (20 points)
Full range of motion (40 points)
Total: maximum 100 points
Preoperative Follow-up exam.
8.2 14.6
19.4 23.9
16.1 19.7
35.7 39.2
79.4 points 97.4 points
Fig. 1. Mid-shaft clavicular in a 22-year-old mountain bike racer non-union 5 months after nonoperative treatment
Fig. 2. Open reduction and internal fixation with reconstruction plate
S. Wentz et al.: Reconstruction plating of clavicular non-union in athletes
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Fig. 4. Well curved and reconstructed clavicle after removal of the plate Fig. 3. Radiographic follow-up after 12 weeks showed a united clavicle
References ogic consolidation (Fig. 3). At 27 weeks after internal fixation the hardware was removed and full painless range of motion of the shoulder was demonstrated (Fig. 4).
Discussion Several opportunities for the operative treatment of clavicular non-union have been described: intramedullary pinning with Steinmann or Knowles pins, Kirschner wires, fixation with wire sutures or interfragmentary screws, and the use of different plates.1,3,4,6–22 Most of these techniques have shown a number of problems. Intramedullary pins do not provide rigid fixation or adequately control rotational forces in the middle third of the clavicle, and it is difficult to insert the pins correctly in this double-curved bone. Fixation with interfragmentary screws or wire sutures shows insufficient immobilization. Thus, many authors prefer internal fixation with compression plating and additional bone grafting with autogenous iliac bone.7,10,11,13,19 We also prefer plating and bone grafting, but use an AO reconstruction plate (regular or titanium), because this plate can be bent easily to the contour of the clavicle. The plate is placed superiorly on the bone and three screws at each side of the non-union give sufficient rigidity. We know that the indications for internal fixation of a clavicular non-union are the subject of controversy, but semi-professional athletes, in particular, will not accept even a mild loss of shoulder function. Therefore we believe that open reduction and internal fixation with reconstruction plating and bone grafting is a successful method for the operative treatment of posttraumatic mid-shaft clavicular non-union.
1. Albrecht HU, Bamert P. Die Claviculafraktur: Therapie und Komplikationen. Helv Chir, Acta 1981;48:571–83. 2. Bar HW. What is the proper position for the back dressing. Sportverletz Sportschaden 1992;6:182–3. 3. Basom WC, Breck LW, Herz JR. Dual grafts for non-union of the clavicle. South Med J 1947;40:898–9. 4. Boehme D, Curtis RJ, DeHaan JT, et al. Non-unions of the midshaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting. J Bone Joint Surg Am 1991;73:1219–26. 5. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160–4. 6. Domingo-Pech J. El enclavado a compresion de las fracturas de clavicula, con tornillo de esponjosa. Barcelona Quirurgica 1971;15:500–20. 7. Edvardsen P, Odegard O. Treatment of posttraumatic clavicular pseudarthrosis. Acta Orthop Scand 1977;48:456–7. 8. Eskola A, Vainionpää S, Myllynen P. Surgery for ununited clavicular fracture. Acta Orthop Scand 1986;57:366–7. 9. Hansis M, Weller S. Die operative Behandlung der Klavikulapseudarthrose. Operat Orthop Traumatol 1989;3:139–44. 10. Herbsthofer B, Schüz W, Mockwitz J. Indikation zur operativen Behandlung von Klavikulafrakturen. Aktuel Traumatol 1994;24: 263–8. 11. Jupiter JB, Leffert RD. Non-union of the clavicle. Associated complications and surgical management. J Bone Joint Surg Am 1987;69:753–60. 12. Koch F, Papadimitriou G, Groher G. Die Claviculapseudarthrose: Entstehung und Behandlung. Unfallheilkunde 1971;74:330–7. 13. Lindenmaier HL, Kuner EH, Becker B. Die Osteosynthese der Clavikula. Chirurg 1991;62:409–13. 14. Manske DJ, Szabo RM. The operative treatment of mid-shaft clavicular non-unions. J Bone Joint Surg Am 1985;67-A:1367– 71. 15. Marsh HO, Hazarian E. Pseudarthrosis of the clavicle. In: Proceedings of the American, British, Canadian, Australian, New Zealand and South African Orthopaedic Associations. J Bone Joint Surg Br 1970;52:793. 16. Neer CS II. Non-union of the clavicle. JAMA 1960;172:1006– 11. 17. Neer CS II. Part I: Fractures about the shoulder. In: Fractures in adults. Vol. 1. Rockwood CA Jr, Green DP, editors. 2nd ed. Philadelphia: JB Lippincott, 1984:702–7. 18. Neviaser JS. The treatment of fractures of the clavicle. Surg Clin North Am 1963;43:1555–63.
272
S. Wentz et al.: Reconstruction plating of clavicular non-union in athletes
19. Pyper JB. Non-union of fractures of the clavicle. Injury 1978;9: 268–70. 20. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop 1968;58:29–42.
21. Sakellarides H. Pseudarthrosis of the clavicle. A report of twenty cases. J Bone Joint Surg Am 1961;43:130–8. 22. Wilkins RM, Johnston RM. Ununited fractures of the clavicle. J Bone Joint Surg Am 1983;65:773–8.