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Surgical treatment of fractures of the distal clavicle with polydioxanone suture tension band wiring: an alternative osteosynthesis
J Orthop Sci (2002) 7:535–537
Surgical treatment of fractures of the distal clavicle with polydioxanone suture tension band wiring: an alternative osteosynthesis Julian W. Mall, Christoph A. Jacobi, Andreas W. Philipp, and Frank J. Peter Department of Surgery, Medical Faculty of the Humboldt-University of Berlin, Klinik für Allgemein-, Viszeral-, Gefäß-und Thoraxchirurgie, Charité, Campus Mitte, Schumannstr. 20/21, 10117 Berlin, Germany
Abstract Fracture of the distal clavicle type II (Neer) is an indication for surgical intervention. We report our experience in 12 patients with acute clavicular fractures and operative treatment with polydioxanone suture (PDS) tension band wiring. The patients were assessed 6 and 12 weeks postoperatively by radiological and clinical evaluation and with the Constant Murley score. All 12 patients had an excellent functional result 12 weeks postoperatively. The Constant Murley score was excellent in all patients. The PDS band can be considered as an alternative osteosynthesis. In the context of the current literature, the advantages and disadvantages of this new procedure are discussed.
Osteosynthesis can be performed either by metal tension band wiring or by plate osteosynthesis.5,6 Based on the hypothesis that patients with solitary dislocation of the acromioclavicular joint and ligament rupture can be treated successfully with polydioxanone suture (PDS) band wiring with a very good functional outcome, we tried to apply this surgical technique to the operative treatment of type II fractures of the lateral clavicle.
Materials and methods Key words Type II fracture · Clavicle · PDS-tension band wiring · Alternative osteosynthesis
Introduction Fracture of the clavicle is one of the most common types of fracture. In 90% of cases, surgery can be avoided.8 Allman classified fractures of the clavicle as distal, central, and medial fractures.1 In contrast to medial and central lesions, the treatment of choice for distal fractures is primary osteosynthesis.2,7 Distal fracture occurs (depending on the author) in 33%–76% of all clavicular fractures.3,10 According to Neer, distal fractures can be classified into three types.9 Type I fractures are lateral to the coracoclavicular ligament and are considered stable. Type II fractures are defined as luxation fractures with extensive ligamental rupture of the coracoclavicular ligament, resulting in shoulder girdle instability. Intraarticular fractures of the acromioclavicular joint are classified as type III.
Offprint requests to: J.W. Mall Received: October 26, 2001 / Accepted: April 1, 2002
Twelve patients (8 men and 4 women) between 21 and 47 years of age underwent operation for a type II (Neer) fracture of the clavicle between April 1999 and February 2000 at the Department of Surgery of the University Hospital Charité, Campus Mitte, in Berlin, Germany. The main complaints of the patients after a traumatic injury (nine bycicle accidents and three sports accidents) to the shoulder or the upper extremity were painful impairment of arm movements and a palpable fracture. Diagnostic x-rays included projection of the shoulder in the anterior-posterior view and the scapula Y projection. After preoperative workup, the patients were taken to the operating room and PDS band tension wiring was performed. The operative approach is described in the following example. In April 1999, a 25-year-old male patient (a professional soccer player) with a painful right shoulder was admitted to the emergency room of the University Hospital Charité. He reported falling on his right shoulder during his daily soccer exercises. His medical and surgical history was unremarkable. On physical examination, a palpable fracture of the lateral third of the right clavicle with painful functional impairment of the right shoulder girdle was found. X-ray revealed a type II (Neer) fracture. The patient was admitted
536
Fig. 1. Preoperative x-ray displaying type II fracture of the distal clavicle
to surgery, and exploration of the fracture and the coracoclavicular and acromioclavicular ligamental rupture was performed. The patient was placed in a beach-chair position with the head turned away from the side of the fracture. A vertical incision 6 cm in length was made at the fracture site. After horizontal splitting of the deltoid–trapezius interval, the fracture site was exposed. The ligamental structures were defined, and then delayed sutures of the coraco-clavicular (conoid and trapezoid portion) and acromioclavicular ligament were inserted. At the distal site of the proximal clavicular fragment, a suture through the clavicle with a 3.2-mm drill was performed in a horizontal direction toward the coracoid process, and a PDS band (Ethicon, Norderstedt, Germany), 10 mm in diameter, was pulled through and prepared in a figure-of-eight around the coracoid process. The coracoid process was not dissected, but the suture was pulled through with a medium-sized Dechamp clamp. After exact reposition of the fracture, the PDS band was tightened and the delayed ligamental sutures were knotted. Wound closure consisted of subcutaneous and intracutaneous suturing, as usual. Figures 1–3 display the pre- and postoperative course and the follow-up of the patient after 12 weeks. The postoperative treatment consisted of fixation in a Gilchrist’s splint for 2 weeks, followed by functional body exercises with a range of movement of 60° abduction for another 4 weeks. Exercises were unlimited after 6 weeks. The other 11 patients were treated in the same manner. In one case, suturing of the ligaments followed by clavicular-coracoidal PDS wiring was sufficient for exact anatomical reposition. In all other cases, an additional PDS suture was necessary for complete restoration.
J.W. Mall et al.: Clavicle fracture and PDS wiring
Fig. 2. Postoperative x-ray after PDS wiring
Fig. 3. 12-week x-ray
Results The median interval between injury and operation was 6 h (range, 3–12 h). After 9 weeks of physiotherapy, all of the patients were free of pain, and shoulder girdle movement was not impaired. After 12 weeks, all patients were assessed clinically, radiologically, and by the Constant Murley score.4 This score includes pain assessment, daily activities, shoulder movement, and strength. The basis of this method is a 100-point score composed of pain (15 points maximum), activities of daily living (20 points maximum), range of motion (40 points maximum), and power (25 points maximum). All patients had an excellent outcome according to these criteria. Only one patient had hypertrophic scar formation. Early mobilization was achieved in all 12 patients, and on follow-up examinations no pseudoarthrosis was seen. Furthermore, no
J.W. Mall et al.: Clavicle fracture and PDS wiring
wound infection or joint impairment was diagnosed. Nine weeks after the operation, the soccer player took active part in soccer exercises, and in the 12th week he was able to support his team in the soccer championships again. Upon re-evaluation of all 12 patients (median followup, 29 months; range, 24–34 months), no arthrosis of the acromioclavicular joint was seen radiologically.
Discussion The lateral fracture is an exception among clavicular fractures. In contrast to fractures of the medial and central thirds of the bone, which are normally treated conservatively, this type II (Neer) fracture should be treated surgically.9 Surgery is indicated because of the extensive additional injury to the coracoclavicular and acromio-clavicular ligament. All established operative techniques have known complications, such as wound infection and loosening or cracking of the implanted material, with the necessity for another operation. In addition to this, the majority of these patients will require another operation for removal of the implanted material. The standard surgical procedure consists of stabilization of the acromioclavicular joint, which is followed by temporary limitation of arm movement. As a result, these patients usually reach all degrees of freedom after removal of the implanted material. Several authors have reported good results in the operative treatment of patients with isolated ruptures of the acromioclavicular ligament (Rockwood type V/ Tossy type III).11,12 These lesions are treated successfully with PDS band wiring with absorbable sutures. In analogy to this technique, we tried to establish a surgical approach to the type II (Neer) fracture of the lateral clavicle. The results in our 12 patients treated with PDS band wiring certainly need further investigation, but
537
they are encouraging. This operation can be interpreted as an alternative osteosynthesis in two ways. On the one hand, there is only a minimal denaturation of the tissue, and on the other hand, the osteosynthetic material completely dissolves, requiring no second operation for removal of the implanted material. Although the x-rays did not show an exact anatomical reposition of the fracture of the distal third of the clavicle, the functional outcome of all patients was excellent. From our point of view, the main advantage of the procedure is the avoidance of a second operation.
References 1. Allman FL. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am 1967;49:774–84. 2. Ballmer FT, Gerber C. Coracoclavicular screw fixation for unstable fractures of the distal clavicle. A report of five cases. J Bone Joint Surg Br 1991;73:291–4. 3. Brunner U, Habermeyer P, Schweiberer L. Die Sonderstellung der lateralen Klavikularfraktur. Orthopäde 1992;21:163–71. 4. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160–4. 5. Eskola A, Vainionpää S, Pätiälä H, et al. Outcome of operative treatment in fresh lateral clavicular fracture. Ann Chir Gynaecol 1987;76:167–9. 6. Hackenbruch W, Regazzoni P, Schwyzer K. Operative Behandlung der lateralen Clavicula-Fraktur mit der “ClaviculaHakenplatte.” Z Unfallchir Vers Med 1994;87:145–51. 7. Hessmann M, Gotzen L, Kirchner R, et al. Therapy and outcome of lateral clavicular fractures. Unfallchir 1997;100:17–23. 8. Moseley HF. The clavicle: its anatomy and function. Clin Orthop 1968;58:17–27. 9. Neer CS. Fractures of the distal third of the clavicle. Clin Orthop 1964;58:43–50. 10. Nordquist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop 1994;300:127–32. 11. Rehm KE, Schultheis KH. Bandersatz mit Polydioxanon (PDS) Unfallchir 1985;11:264–73. 12. Rustemeier M, Kulenkampff HA. Die operative Behandlung der Akromioklavikulargelenk-Sprengung mit einer resorbierbaren PDS -Kordel. Unfallchir 1990;16:70–4.
Surgical treatment of fractures of the distal clavicle with polydioxanone suture tension band wiring: an alternative osteosynthesis Julian W. Mall, Christoph A. Jacobi, Andreas W. Philipp, and Frank J. Peter Department of Surgery, Medical Faculty of the Humboldt-University of Berlin, Klinik für Allgemein-, Viszeral-, Gefäß-und Thoraxchirurgie, Charité, Campus Mitte, Schumannstr. 20/21, 10117 Berlin, Germany
Abstract Fracture of the distal clavicle type II (Neer) is an indication for surgical intervention. We report our experience in 12 patients with acute clavicular fractures and operative treatment with polydioxanone suture (PDS) tension band wiring. The patients were assessed 6 and 12 weeks postoperatively by radiological and clinical evaluation and with the Constant Murley score. All 12 patients had an excellent functional result 12 weeks postoperatively. The Constant Murley score was excellent in all patients. The PDS band can be considered as an alternative osteosynthesis. In the context of the current literature, the advantages and disadvantages of this new procedure are discussed.
Osteosynthesis can be performed either by metal tension band wiring or by plate osteosynthesis.5,6 Based on the hypothesis that patients with solitary dislocation of the acromioclavicular joint and ligament rupture can be treated successfully with polydioxanone suture (PDS) band wiring with a very good functional outcome, we tried to apply this surgical technique to the operative treatment of type II fractures of the lateral clavicle.
Materials and methods Key words Type II fracture · Clavicle · PDS-tension band wiring · Alternative osteosynthesis
Introduction Fracture of the clavicle is one of the most common types of fracture. In 90% of cases, surgery can be avoided.8 Allman classified fractures of the clavicle as distal, central, and medial fractures.1 In contrast to medial and central lesions, the treatment of choice for distal fractures is primary osteosynthesis.2,7 Distal fracture occurs (depending on the author) in 33%–76% of all clavicular fractures.3,10 According to Neer, distal fractures can be classified into three types.9 Type I fractures are lateral to the coracoclavicular ligament and are considered stable. Type II fractures are defined as luxation fractures with extensive ligamental rupture of the coracoclavicular ligament, resulting in shoulder girdle instability. Intraarticular fractures of the acromioclavicular joint are classified as type III.
Offprint requests to: J.W. Mall Received: October 26, 2001 / Accepted: April 1, 2002
Twelve patients (8 men and 4 women) between 21 and 47 years of age underwent operation for a type II (Neer) fracture of the clavicle between April 1999 and February 2000 at the Department of Surgery of the University Hospital Charité, Campus Mitte, in Berlin, Germany. The main complaints of the patients after a traumatic injury (nine bycicle accidents and three sports accidents) to the shoulder or the upper extremity were painful impairment of arm movements and a palpable fracture. Diagnostic x-rays included projection of the shoulder in the anterior-posterior view and the scapula Y projection. After preoperative workup, the patients were taken to the operating room and PDS band tension wiring was performed. The operative approach is described in the following example. In April 1999, a 25-year-old male patient (a professional soccer player) with a painful right shoulder was admitted to the emergency room of the University Hospital Charité. He reported falling on his right shoulder during his daily soccer exercises. His medical and surgical history was unremarkable. On physical examination, a palpable fracture of the lateral third of the right clavicle with painful functional impairment of the right shoulder girdle was found. X-ray revealed a type II (Neer) fracture. The patient was admitted
536
Fig. 1. Preoperative x-ray displaying type II fracture of the distal clavicle
to surgery, and exploration of the fracture and the coracoclavicular and acromioclavicular ligamental rupture was performed. The patient was placed in a beach-chair position with the head turned away from the side of the fracture. A vertical incision 6 cm in length was made at the fracture site. After horizontal splitting of the deltoid–trapezius interval, the fracture site was exposed. The ligamental structures were defined, and then delayed sutures of the coraco-clavicular (conoid and trapezoid portion) and acromioclavicular ligament were inserted. At the distal site of the proximal clavicular fragment, a suture through the clavicle with a 3.2-mm drill was performed in a horizontal direction toward the coracoid process, and a PDS band (Ethicon, Norderstedt, Germany), 10 mm in diameter, was pulled through and prepared in a figure-of-eight around the coracoid process. The coracoid process was not dissected, but the suture was pulled through with a medium-sized Dechamp clamp. After exact reposition of the fracture, the PDS band was tightened and the delayed ligamental sutures were knotted. Wound closure consisted of subcutaneous and intracutaneous suturing, as usual. Figures 1–3 display the pre- and postoperative course and the follow-up of the patient after 12 weeks. The postoperative treatment consisted of fixation in a Gilchrist’s splint for 2 weeks, followed by functional body exercises with a range of movement of 60° abduction for another 4 weeks. Exercises were unlimited after 6 weeks. The other 11 patients were treated in the same manner. In one case, suturing of the ligaments followed by clavicular-coracoidal PDS wiring was sufficient for exact anatomical reposition. In all other cases, an additional PDS suture was necessary for complete restoration.
J.W. Mall et al.: Clavicle fracture and PDS wiring
Fig. 2. Postoperative x-ray after PDS wiring
Fig. 3. 12-week x-ray
Results The median interval between injury and operation was 6 h (range, 3–12 h). After 9 weeks of physiotherapy, all of the patients were free of pain, and shoulder girdle movement was not impaired. After 12 weeks, all patients were assessed clinically, radiologically, and by the Constant Murley score.4 This score includes pain assessment, daily activities, shoulder movement, and strength. The basis of this method is a 100-point score composed of pain (15 points maximum), activities of daily living (20 points maximum), range of motion (40 points maximum), and power (25 points maximum). All patients had an excellent outcome according to these criteria. Only one patient had hypertrophic scar formation. Early mobilization was achieved in all 12 patients, and on follow-up examinations no pseudoarthrosis was seen. Furthermore, no
J.W. Mall et al.: Clavicle fracture and PDS wiring
wound infection or joint impairment was diagnosed. Nine weeks after the operation, the soccer player took active part in soccer exercises, and in the 12th week he was able to support his team in the soccer championships again. Upon re-evaluation of all 12 patients (median followup, 29 months; range, 24–34 months), no arthrosis of the acromioclavicular joint was seen radiologically.
Discussion The lateral fracture is an exception among clavicular fractures. In contrast to fractures of the medial and central thirds of the bone, which are normally treated conservatively, this type II (Neer) fracture should be treated surgically.9 Surgery is indicated because of the extensive additional injury to the coracoclavicular and acromio-clavicular ligament. All established operative techniques have known complications, such as wound infection and loosening or cracking of the implanted material, with the necessity for another operation. In addition to this, the majority of these patients will require another operation for removal of the implanted material. The standard surgical procedure consists of stabilization of the acromioclavicular joint, which is followed by temporary limitation of arm movement. As a result, these patients usually reach all degrees of freedom after removal of the implanted material. Several authors have reported good results in the operative treatment of patients with isolated ruptures of the acromioclavicular ligament (Rockwood type V/ Tossy type III).11,12 These lesions are treated successfully with PDS band wiring with absorbable sutures. In analogy to this technique, we tried to establish a surgical approach to the type II (Neer) fracture of the lateral clavicle. The results in our 12 patients treated with PDS band wiring certainly need further investigation, but
537
they are encouraging. This operation can be interpreted as an alternative osteosynthesis in two ways. On the one hand, there is only a minimal denaturation of the tissue, and on the other hand, the osteosynthetic material completely dissolves, requiring no second operation for removal of the implanted material. Although the x-rays did not show an exact anatomical reposition of the fracture of the distal third of the clavicle, the functional outcome of all patients was excellent. From our point of view, the main advantage of the procedure is the avoidance of a second operation.
References 1. Allman FL. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am 1967;49:774–84. 2. Ballmer FT, Gerber C. Coracoclavicular screw fixation for unstable fractures of the distal clavicle. A report of five cases. J Bone Joint Surg Br 1991;73:291–4. 3. Brunner U, Habermeyer P, Schweiberer L. Die Sonderstellung der lateralen Klavikularfraktur. Orthopäde 1992;21:163–71. 4. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160–4. 5. Eskola A, Vainionpää S, Pätiälä H, et al. Outcome of operative treatment in fresh lateral clavicular fracture. Ann Chir Gynaecol 1987;76:167–9. 6. Hackenbruch W, Regazzoni P, Schwyzer K. Operative Behandlung der lateralen Clavicula-Fraktur mit der “ClaviculaHakenplatte.” Z Unfallchir Vers Med 1994;87:145–51. 7. Hessmann M, Gotzen L, Kirchner R, et al. Therapy and outcome of lateral clavicular fractures. Unfallchir 1997;100:17–23. 8. Moseley HF. The clavicle: its anatomy and function. Clin Orthop 1968;58:17–27. 9. Neer CS. Fractures of the distal third of the clavicle. Clin Orthop 1964;58:43–50. 10. Nordquist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop 1994;300:127–32. 11. Rehm KE, Schultheis KH. Bandersatz mit Polydioxanon (PDS) Unfallchir 1985;11:264–73. 12. Rustemeier M, Kulenkampff HA. Die operative Behandlung der Akromioklavikulargelenk-Sprengung mit einer resorbierbaren PDS -Kordel. Unfallchir 1990;16:70–4.