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Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation
Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation Erik L. Slette, B.A., Jacob D. Mikula, B.S., Travis Lee Turnbull, Ph.D., and Thomas R. Hackett, M.D.
Abstract: Currently, open reductioneinternal fixation using contoured plates or intramedullary nails is considered the standard operative treatment for midshaft clavicle fractures because of the immediate rigid stability provided by the fixation device. In addition, autologous iliac crest bone graft has proved to augment osteosynthesis during internal fixation of nonunion fractures through the release of osteogenic factors. The purpose of this article is to describe a surgical technique developed to reduce donor-site morbidity and improve functional and objective outcomes after open reductioneinternal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.
T
he clavicle is one of the most commonly fractured bones, representing 5% to 15% of all fractures.1 Fractures of the midshaft account for approximately 80% of all clavicular fractures because the junction between the lateral and middle third is the thinnest portion of the bone and lacks muscular and ligamentous reinforcement.2,3 Historically, fractures of the middle third of the clavicle were managed nonoperatively because closed treatment was believed to yield a low nonunion rate and minimal functional impairment.4 In addition, clavicular malunion, which occurs to some degree in approximately two-thirds of midshaft clavicle fractures, was previously described as being solely a radiographic anomaly with no clinical significance.2,5-8 However, more recent studies have suggested that operative treatment results in increased patient satisfaction, superior functional capabilities, and decreased rates of nonunion and malunion when compared with nonoperative management.9-12 From the Steadman Philippon Research Institute (E.L.S., J.D.M., T.L.T., T.R.H.); and The Steadman Clinic (T.R.H.), Vail, Colorado, U.S.A. The authors report the following potential conflict of interest or source of funding: T.R.H. receives support from Arthrex, Sonoma Orthopaedics, and NICE. This article was funded internally by the Steadman Philippon Research Institute. Received November 18, 2015; accepted February 2, 2016. Address correspondence to Thomas R. Hackett, M.D., Steadman Philippon Research Institute, 181 W Meadow Dr., Ste 1000, Vail, CO 81657, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/151077/$36.00 http://dx.doi.org/10.1016/j.eats.2016.02.008
Operative management of midshaft clavicle fractures may involve the use of various techniques for reduction and fixation.12 Currently, open reductioneinternal fixation is considered the gold-standard treatment because of the immediate rigid stability provided by the fixation device.2,11,13-17 Internal fixation of midshaft clavicle fractures may involve the use of contoured plates or intramedullary nails.18-20 In addition, autologous iliac crest bone graft (ICBG) has proved to augment osteosynthesis during fixation of nonunion fractures through the release of osteogenic factors.2,11,13-17 However, studies have associated ICBG harvesting with significant donor-site morbidity, including neurologic and vascular injury, incisional hernia, donor-site fracture, and deep infection.21-24 Therefore, the purpose of this article was to describe a surgical technique developed to reduce donor-site morbidity and improve functional outcomes after open reductioneinternal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.
Technique This technical note describes open reductioneinternal fixation of a midshaft clavicle fracture with autologous bone graft placement through local autograft harvest and plate fixation (Video 1). Pearls and pitfalls of this technique are described in Table 1, and advantages and limitations are presented in Table 2.
Arthroscopy Techniques, Vol 5, No 3 (June), 2016: pp e557-e562
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Table 1. Pearls and Pitfalls of Surgical Technique Pearls Minimize destruction of the periosteum and the soft-tissue envelope around the clavicle to facilitate healing. Use a high drilling speed and large drilling force to minimize the increase in bone temperature. Avoid preserving bone autograft in saline solution because this will wash away osteogenic growth factors. Pitfalls Osteonecrosis of bone autograft Excessive irrigation washing away osteogenic growth factors
Patient Positioning The patient is placed in the beach-chair position with the axilla and hand excluded from the surgical field. A 10-cm incision is made with a No. 15 scalpel blade superior to the site of clavicle injury in concordance with the Langer lines (Fig 1). Fracture Identification and Provisional Reduction Once the fracture is identified through sharp dissection, a cortical read is obtained by removing the most minimal amount of soft tissue to preserve the soft-tissue envelope around the fracture site (Fig 2). After soft-tissue mobilization and visualization of the clavicular pathology, the clavicle fracture is provisionally reduced using bone reduction forceps to facilitate the selection of an appropriately sized fixation plate (Figs 3-5). Preparation for Plate Fixation When plate fixation is being performed, a precontoured titanium plate (Acumed, Hillsboro, OR) is used based on the length of the clavicle and extent of the pathology. The plate length is selected so that 4 cortices are drilled on either side of the fracture site. With the plate as a guide, a 2.8-mm drill bit (Acumed) is used to ream pilot holes in preparation for screw placement (Fig 6). To minimize the risk of osteonecrosis, all drilling is performed at maximum revolutions per minute. In addition, irrigation is applied to the drill bit before initiation and during drilling to reduce heat aggregation. To avoid washing away osteogenic factors from
Fig 1. The patient is placed in the beach-chair position (left shoulder) with the axilla and hand excluded from the surgical field. A 10-cm incision is made with a No. 15 scalpel blade superior to the site of clavicle injury.
the bone autograft, irrigation is not applied during the removal of the drill bit from the bone. Autograft Harvesting and Preservation After drilling of each pilot hole, the bony remnants are collected from the flutes of the drill bit (Fig 7) with a dental pick. In addition to those from the drill flutes, any bony remnants that accumulate adjacent to the drilling site are collected and preserved with the others in a sterile cup (without saline solution) while awaiting placement within the fracture site (Fig 8). Surgical Depth Measurement and Plate Fixation Before plate fixation, a surgical depth-measurement device (Sklar, West Chester, PA) is used to determine the depth of each pilot hole (Fig 9). Once the plate has been fixed and the depth measurements determined, screws (Acumed) are placed in either a corticocancellous locking or non-locking configuration (Fig 10). Fluoroscopy After plate fixation, fluoroscopy is used to confirm the position and length of the fixation screws (Fig 11).
Table 2. Advantages and Limitations of Surgical Technique Advantages Reduced operating time and operating costs because of the lack of a secondary incision for iliac crest autograft harvest No second-incision donor-site morbidity Improved osteosynthesis because of the presence of osteogenic factors in the autograft Limitations Possibility of yielding less bone autograft than an iliac crest bone autograft Risk of heat-induced osteonecrosis due to pilot-hole drilling, which may cause breakdown of the bone around the implantation site, leading to fixation loosening
Fig 2. Sharp dissection is performed with a No. 15 scalpel blade to allow for visualization of the fracture site. A minimal amount of soft tissue is removed to preserve the soft-tissue envelope around the fracture site (left shoulder).
TREATMENT OF MIDSHAFT CLAVICLE FRACTURES
Fig 3. Bone reduction forceps are used to provisionally reduce the butterfly fragment in preparation for precontoured fixation plate sizing (left shoulder).
Irrigation, Autograft Placement, and Closure Irrigation is applied after fluoroscopy to clean the fracture site. Then, the accumulated bone autograft is packed within the posterior aspect of the fracture site with a forceps (Fig 12). After placement of the bone autograft, the incision is closed with a focus on preservation and repair of the periosteum and soft-tissue envelope. The patient’s extremity is immobilized for 2 weeks in a sling, followed by a gradual return to motion.
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Fig 5. In this patient, an 8-hole precontoured titanium plate is used based on the length of the clavicle and extent of the pathology (left shoulder). The plate size is selected so that 4 cortices are drilled on each side of the fracture site.
morbidity and improve functional outcomes after open reductioneinternal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation. The primary advantage of this technique is that it eliminates the need for ICBG harvesting, reducing the risk of associated second-incision donor-site morbidity,
Discussion Surgical management of fractures involving the middle third of the clavicle is becoming more widely adopted.2,6,13,25 Open reductioneinternal fixation with the implementation of either contoured plates or intramedullary nails is a commonly used technique for midshaft clavicular fracture fixation.2,11,13-20 In instances in which the indication for surgical treatment is fracture nonunion, autologous ICBG may be added to provide a scaffolding for growth and facilitate osteosynthesis.2,11,13-17 However, studies have associated ICBG harvesting with significant donor-site morbidity. Therefore, the purpose of this article was to describe a surgical technique developed to reduce donor-site
Fig 4. In this particular case, a K-wire is drilled into the superior aspect of the butterfly fragment to ensure the stability of the reduced fragment (left shoulder).
Fig 6. With the precontoured plate used as a guide, a 2.8-mm drill bit is used to ream pilot holes in the superior aspect of the clavicle in preparation for screw placement (left shoulder).
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Fig 9. A surgical depth-measurement device is used to determine the depth of the medial pilot hole before screw placement (left shoulder).
Fig 7. A dental pick is used to harvest bone autograft from the flutes of the drill bit after the drilling of each pilot hole.
such as neurovascular injury, incisional hernia, donorsite fracture, and deep infection.21-24 In addition, because of the lack of a secondary incision for iliac crest autograft harvest, the time spent in the operating room and total operating costs are reduced. This surgical
Fig 8. After harvesting of the bone autograft from the flutes of the drill bit, the autograft is placed in a sterile cup (with no saline solution) for preservation. Saline solution is not added to the cup to avoid washing away important osteogenic factors contained within the autograft.
technique has been used for 6 years, yielding favorable postoperative complication and union rates. The primary limitation of this technique is that it may yield less bone autograft than an ICBG. However, further research is warranted because there is currently no literature regarding the quantity of bone graft obtained from the iliac crest during autograft harvesting. An additional potential disadvantage inherent to all fracture treatment strategies involving bone drilling is heat-induced osteonecrosis, which causes breakdown of bone around the implantation site leading to loosening of the fixation.26 Nevertheless, this procedure aims to make the best use of drilling by applying autograft tissue that may otherwise be discarded. Heat-induced osteonecrosis is an important factor to minimize in this technique to maintain the viability of the bone graft. Before rigid fixation of the contoured plate, a drill bit is used to create pilot holes in the bone to reduce the likelihood of further bone fracture during cortical screw placement. During the bone-drilling process, the temperature within the bone adjacent to the drill site rises, which can result in osteonecrosis.27 The exact threshold temperature for osteonecrosis in human cortical bone is not known. However, most investigators studying the topic of bone necrosis have
Fig 10. A screwdriver (Acumed) is used to place screws in a laterally located pilot hole (left shoulder). The screws are placed in either a corticocancellous locking or non-locking configuration.
TREATMENT OF MIDSHAFT CLAVICLE FRACTURES
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Acknowledgment The authors thank Chris Jacobsen and Barry Eckhaus for their expertise in producing and editing the multimedia components contained within this article.
References
Fig 11. Fluoroscopy is used to confirm the position and length of the fixation screws (left shoulder, posterior-anterior view).
agreed that an average temperature of 47 C for 1 minute serves as a threshold above which the necrosis of human bone occurs.28-33 In a comprehensive review of bone-drilling studies, Pandey and Panda27 suggested that the temperature generated during bone drilling is dependent on variables including drill bit diameter, drill revolutions per minute, axial drilling forces, and irrigation. Although there is no clear indication about the optimum drilling speed or force from past studies, most investigators have recommended a high drilling speed and large forces for minimum temperature generation, although drilling forces should be tempered to reduce to risk of lung puncture or neurovascular injury. In addition to providing drilling recommendations, investigators have asserted that irrigation (internal or external) is the most important factor in avoiding bone necrosis.27 However, it has been suggested that external irrigation may reduce effective osteosynthesis by washing away important osteogenic growth factors surrounding the fracture site. The described surgical technique is a safe, effective, and reproducible approach to treating midshaft clavicle fractures. We recommend our method of reduction and fixation for clavicle fractures and encourage further studies to investigate and assess our technique.
Fig 12. The bone autograft that accumulated in the sterile cup (Fig 8) is packed within the posterior aspect of the fracture site with a forceps (left shoulder).
1. Zehir S, Akgül T, Zehir R. Results of midshaft clavicle fractures treated with expandable, elastic and locking intramedullary nails. Acta Orthop Traumatol Turc 2015;49: 13-17. 2. Canadian Orthopedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2007;89:1-10. 3. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg 2007;15:239-248. 4. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am 2009;91:447-460. 5. Crenshaw AH. Fractures of the shoulder girdle, arm and forearm. In: Crenshaw AH, ed. Campbell’s operative orthopaedics. Ed 8. St Louis: Mosby Year Book, 1992;9891053. 6. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am 2003;85: 790-797. 7. Hillen RJ, Burger BJ, Poll RG, de Gast A, Robinson CM. Malunion after midshaft clavicle fractures in adults. Acta Orthop 2010;81:273-279. 8. Smekal V, Oberladstaetter J, Struve P, Krappinger D. Shaft fractures of the clavicle: Current concepts. Arch Orthop Trauma Surg 2009;129:807-815. 9. Altamimi SA, McKee MD. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: Surgical technique. J Bone Joint Surg Am 2008;90:1-8. 10. McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: A meta-analysis of randomized clinical trials. J Bone Joint Surg Am 2012;94:675-684. 11. Robinson CM, Goudie EB, Murray IR, et al. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial. J Bone Joint Surg Am 2013;95:1576-1584. 12. Smith SD, Wijdicks CA, Jansson KS, et al. Stability of midshaft clavicle fractures after plate fixation versus intramedullary repair and after hardware removal. Knee Surg Sports Traumatol Arthrosc 2014;22:448-455. 13. van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: Current concepts review. J Shoulder Elbow Surg 2012;21:423-429. 14. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of acute midshaft clavicle fractures: Systematic review of 2144 fractures: On behalf of the evidence-based orthopaedic trauma working group. J Orthop Trauma 2005;19:504-507. 15. Ebraheim NA, Mekhail AO, Darwich M. Open reduction and internal fixation with bone grafting of clavicular nonunion. J Trauma 1997;42:701-704.
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16. Olsen BS, Vaesel MT, Sojbjerg JO. Treatment of midshaft clavicular nonunion with plate fixation and autologous bone grafting. J Shoulder Elbow Surg 1995;4:337-344. 17. Marti RK, Nolte PA, Kerkhoffs GM, Besselaar PP, Schaap GR. Operative treatment of mid-shaft clavicular non-union. Int Orthop 2003;27:131-135. 18. Houwert RM, Wijdicks FJ, Steins Bisschop C, Verleisdonk EJ, Kruyt M. Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: A systematic review. Int Orthop 2012;36:579-585. 19. Hartmann F, Hessmann MH, Gercek E, Rommens PM. Elastic intramedullary nailing of midclavicular fractures. Acta Chir Belg 2008;108:428-432. 20. Duan X, Zhong G, Cen S, Huang F, Xiang Z. Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: A meta-analysis of randomized controlled trials. J Shoulder Elbow Surg 2011;20:10081015. 21. Ebraheim NA, Elgafy H, Xu R. Bone-graft harvesting from iliac and fibular donor sites: Techniques and complications. J Am Acad Orthop Surg 2001;9:210-218. 22. Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA. Complications iliac crest bone graft harvesting. Clin Orthop Relat Res 1996;329:300-309. 23. Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma 1989;3:192-195. 24. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and functional assessment. Clin Orthop Relat Res 1997;339:76-81.
25. McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40. 26. Pallan FG. Histological change in bone after insertion of skeletal fixation pins. J Oral Surg Anesth Hosp Dent Serv 1960;18:400-408. 27. Pandey RK, Panda SS. Drilling of bone: A comprehensive review. J Clin Orthop Trauma 2013;4:15-30. 28. Eriksson RA, Albrektsson T. Temperature threshold levels for heat-induced bone tissue injury: A vital-microscopic study in the rabbit. J Prosthet Dent 1983;50:101-107. 29. Eriksson RA, Albrektsson T, Magnusson B. Assessment of bone viability after heat trauma. a histological, histochemical and vital microscopic study in the rabbit. Scand J Plast Reconstr Surg 1984;18:261-268. 30. Eriksson RA, Albrektsson T. The effect of heat on bone regeneration: An experimental study in the rabbit using bone growth chamber. J Oral Maxillofac Surg 1984;42:705-711. 31. Eriksson AR, Albrektsson T, Albrektsson B. Heat caused by drilling cortical bone. temperature measured in vivo in patients and animals. Acta Orthop Scand 1984;55:629-631. 32. Eriksson RA, Albrektsson T, Grane B, Mcqueen D. Thermal injury to bone a vital-microscopic description of heat effects. Int J Oral Surg 1982;11:115-121. 33. Eriksson RA, Adell R. Temperatures during drilling for the placement of implants using the osseointegration technique. J Oral Maxillofac Surg 1986;44:4-7.
Abstract: Currently, open reductioneinternal fixation using contoured plates or intramedullary nails is considered the standard operative treatment for midshaft clavicle fractures because of the immediate rigid stability provided by the fixation device. In addition, autologous iliac crest bone graft has proved to augment osteosynthesis during internal fixation of nonunion fractures through the release of osteogenic factors. The purpose of this article is to describe a surgical technique developed to reduce donor-site morbidity and improve functional and objective outcomes after open reductioneinternal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.
T
he clavicle is one of the most commonly fractured bones, representing 5% to 15% of all fractures.1 Fractures of the midshaft account for approximately 80% of all clavicular fractures because the junction between the lateral and middle third is the thinnest portion of the bone and lacks muscular and ligamentous reinforcement.2,3 Historically, fractures of the middle third of the clavicle were managed nonoperatively because closed treatment was believed to yield a low nonunion rate and minimal functional impairment.4 In addition, clavicular malunion, which occurs to some degree in approximately two-thirds of midshaft clavicle fractures, was previously described as being solely a radiographic anomaly with no clinical significance.2,5-8 However, more recent studies have suggested that operative treatment results in increased patient satisfaction, superior functional capabilities, and decreased rates of nonunion and malunion when compared with nonoperative management.9-12 From the Steadman Philippon Research Institute (E.L.S., J.D.M., T.L.T., T.R.H.); and The Steadman Clinic (T.R.H.), Vail, Colorado, U.S.A. The authors report the following potential conflict of interest or source of funding: T.R.H. receives support from Arthrex, Sonoma Orthopaedics, and NICE. This article was funded internally by the Steadman Philippon Research Institute. Received November 18, 2015; accepted February 2, 2016. Address correspondence to Thomas R. Hackett, M.D., Steadman Philippon Research Institute, 181 W Meadow Dr., Ste 1000, Vail, CO 81657, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/151077/$36.00 http://dx.doi.org/10.1016/j.eats.2016.02.008
Operative management of midshaft clavicle fractures may involve the use of various techniques for reduction and fixation.12 Currently, open reductioneinternal fixation is considered the gold-standard treatment because of the immediate rigid stability provided by the fixation device.2,11,13-17 Internal fixation of midshaft clavicle fractures may involve the use of contoured plates or intramedullary nails.18-20 In addition, autologous iliac crest bone graft (ICBG) has proved to augment osteosynthesis during fixation of nonunion fractures through the release of osteogenic factors.2,11,13-17 However, studies have associated ICBG harvesting with significant donor-site morbidity, including neurologic and vascular injury, incisional hernia, donor-site fracture, and deep infection.21-24 Therefore, the purpose of this article was to describe a surgical technique developed to reduce donor-site morbidity and improve functional outcomes after open reductioneinternal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.
Technique This technical note describes open reductioneinternal fixation of a midshaft clavicle fracture with autologous bone graft placement through local autograft harvest and plate fixation (Video 1). Pearls and pitfalls of this technique are described in Table 1, and advantages and limitations are presented in Table 2.
Arthroscopy Techniques, Vol 5, No 3 (June), 2016: pp e557-e562
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Table 1. Pearls and Pitfalls of Surgical Technique Pearls Minimize destruction of the periosteum and the soft-tissue envelope around the clavicle to facilitate healing. Use a high drilling speed and large drilling force to minimize the increase in bone temperature. Avoid preserving bone autograft in saline solution because this will wash away osteogenic growth factors. Pitfalls Osteonecrosis of bone autograft Excessive irrigation washing away osteogenic growth factors
Patient Positioning The patient is placed in the beach-chair position with the axilla and hand excluded from the surgical field. A 10-cm incision is made with a No. 15 scalpel blade superior to the site of clavicle injury in concordance with the Langer lines (Fig 1). Fracture Identification and Provisional Reduction Once the fracture is identified through sharp dissection, a cortical read is obtained by removing the most minimal amount of soft tissue to preserve the soft-tissue envelope around the fracture site (Fig 2). After soft-tissue mobilization and visualization of the clavicular pathology, the clavicle fracture is provisionally reduced using bone reduction forceps to facilitate the selection of an appropriately sized fixation plate (Figs 3-5). Preparation for Plate Fixation When plate fixation is being performed, a precontoured titanium plate (Acumed, Hillsboro, OR) is used based on the length of the clavicle and extent of the pathology. The plate length is selected so that 4 cortices are drilled on either side of the fracture site. With the plate as a guide, a 2.8-mm drill bit (Acumed) is used to ream pilot holes in preparation for screw placement (Fig 6). To minimize the risk of osteonecrosis, all drilling is performed at maximum revolutions per minute. In addition, irrigation is applied to the drill bit before initiation and during drilling to reduce heat aggregation. To avoid washing away osteogenic factors from
Fig 1. The patient is placed in the beach-chair position (left shoulder) with the axilla and hand excluded from the surgical field. A 10-cm incision is made with a No. 15 scalpel blade superior to the site of clavicle injury.
the bone autograft, irrigation is not applied during the removal of the drill bit from the bone. Autograft Harvesting and Preservation After drilling of each pilot hole, the bony remnants are collected from the flutes of the drill bit (Fig 7) with a dental pick. In addition to those from the drill flutes, any bony remnants that accumulate adjacent to the drilling site are collected and preserved with the others in a sterile cup (without saline solution) while awaiting placement within the fracture site (Fig 8). Surgical Depth Measurement and Plate Fixation Before plate fixation, a surgical depth-measurement device (Sklar, West Chester, PA) is used to determine the depth of each pilot hole (Fig 9). Once the plate has been fixed and the depth measurements determined, screws (Acumed) are placed in either a corticocancellous locking or non-locking configuration (Fig 10). Fluoroscopy After plate fixation, fluoroscopy is used to confirm the position and length of the fixation screws (Fig 11).
Table 2. Advantages and Limitations of Surgical Technique Advantages Reduced operating time and operating costs because of the lack of a secondary incision for iliac crest autograft harvest No second-incision donor-site morbidity Improved osteosynthesis because of the presence of osteogenic factors in the autograft Limitations Possibility of yielding less bone autograft than an iliac crest bone autograft Risk of heat-induced osteonecrosis due to pilot-hole drilling, which may cause breakdown of the bone around the implantation site, leading to fixation loosening
Fig 2. Sharp dissection is performed with a No. 15 scalpel blade to allow for visualization of the fracture site. A minimal amount of soft tissue is removed to preserve the soft-tissue envelope around the fracture site (left shoulder).
TREATMENT OF MIDSHAFT CLAVICLE FRACTURES
Fig 3. Bone reduction forceps are used to provisionally reduce the butterfly fragment in preparation for precontoured fixation plate sizing (left shoulder).
Irrigation, Autograft Placement, and Closure Irrigation is applied after fluoroscopy to clean the fracture site. Then, the accumulated bone autograft is packed within the posterior aspect of the fracture site with a forceps (Fig 12). After placement of the bone autograft, the incision is closed with a focus on preservation and repair of the periosteum and soft-tissue envelope. The patient’s extremity is immobilized for 2 weeks in a sling, followed by a gradual return to motion.
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Fig 5. In this patient, an 8-hole precontoured titanium plate is used based on the length of the clavicle and extent of the pathology (left shoulder). The plate size is selected so that 4 cortices are drilled on each side of the fracture site.
morbidity and improve functional outcomes after open reductioneinternal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation. The primary advantage of this technique is that it eliminates the need for ICBG harvesting, reducing the risk of associated second-incision donor-site morbidity,
Discussion Surgical management of fractures involving the middle third of the clavicle is becoming more widely adopted.2,6,13,25 Open reductioneinternal fixation with the implementation of either contoured plates or intramedullary nails is a commonly used technique for midshaft clavicular fracture fixation.2,11,13-20 In instances in which the indication for surgical treatment is fracture nonunion, autologous ICBG may be added to provide a scaffolding for growth and facilitate osteosynthesis.2,11,13-17 However, studies have associated ICBG harvesting with significant donor-site morbidity. Therefore, the purpose of this article was to describe a surgical technique developed to reduce donor-site
Fig 4. In this particular case, a K-wire is drilled into the superior aspect of the butterfly fragment to ensure the stability of the reduced fragment (left shoulder).
Fig 6. With the precontoured plate used as a guide, a 2.8-mm drill bit is used to ream pilot holes in the superior aspect of the clavicle in preparation for screw placement (left shoulder).
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Fig 9. A surgical depth-measurement device is used to determine the depth of the medial pilot hole before screw placement (left shoulder).
Fig 7. A dental pick is used to harvest bone autograft from the flutes of the drill bit after the drilling of each pilot hole.
such as neurovascular injury, incisional hernia, donorsite fracture, and deep infection.21-24 In addition, because of the lack of a secondary incision for iliac crest autograft harvest, the time spent in the operating room and total operating costs are reduced. This surgical
Fig 8. After harvesting of the bone autograft from the flutes of the drill bit, the autograft is placed in a sterile cup (with no saline solution) for preservation. Saline solution is not added to the cup to avoid washing away important osteogenic factors contained within the autograft.
technique has been used for 6 years, yielding favorable postoperative complication and union rates. The primary limitation of this technique is that it may yield less bone autograft than an ICBG. However, further research is warranted because there is currently no literature regarding the quantity of bone graft obtained from the iliac crest during autograft harvesting. An additional potential disadvantage inherent to all fracture treatment strategies involving bone drilling is heat-induced osteonecrosis, which causes breakdown of bone around the implantation site leading to loosening of the fixation.26 Nevertheless, this procedure aims to make the best use of drilling by applying autograft tissue that may otherwise be discarded. Heat-induced osteonecrosis is an important factor to minimize in this technique to maintain the viability of the bone graft. Before rigid fixation of the contoured plate, a drill bit is used to create pilot holes in the bone to reduce the likelihood of further bone fracture during cortical screw placement. During the bone-drilling process, the temperature within the bone adjacent to the drill site rises, which can result in osteonecrosis.27 The exact threshold temperature for osteonecrosis in human cortical bone is not known. However, most investigators studying the topic of bone necrosis have
Fig 10. A screwdriver (Acumed) is used to place screws in a laterally located pilot hole (left shoulder). The screws are placed in either a corticocancellous locking or non-locking configuration.
TREATMENT OF MIDSHAFT CLAVICLE FRACTURES
e561
Acknowledgment The authors thank Chris Jacobsen and Barry Eckhaus for their expertise in producing and editing the multimedia components contained within this article.
References
Fig 11. Fluoroscopy is used to confirm the position and length of the fixation screws (left shoulder, posterior-anterior view).
agreed that an average temperature of 47 C for 1 minute serves as a threshold above which the necrosis of human bone occurs.28-33 In a comprehensive review of bone-drilling studies, Pandey and Panda27 suggested that the temperature generated during bone drilling is dependent on variables including drill bit diameter, drill revolutions per minute, axial drilling forces, and irrigation. Although there is no clear indication about the optimum drilling speed or force from past studies, most investigators have recommended a high drilling speed and large forces for minimum temperature generation, although drilling forces should be tempered to reduce to risk of lung puncture or neurovascular injury. In addition to providing drilling recommendations, investigators have asserted that irrigation (internal or external) is the most important factor in avoiding bone necrosis.27 However, it has been suggested that external irrigation may reduce effective osteosynthesis by washing away important osteogenic growth factors surrounding the fracture site. The described surgical technique is a safe, effective, and reproducible approach to treating midshaft clavicle fractures. We recommend our method of reduction and fixation for clavicle fractures and encourage further studies to investigate and assess our technique.
Fig 12. The bone autograft that accumulated in the sterile cup (Fig 8) is packed within the posterior aspect of the fracture site with a forceps (left shoulder).
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