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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 128-131

Nonunion of clavicle treated with precontoured locking compression plate fixation and bone grafting: A long-term outcome


Department of Orthopaedics, Government Medical College, Baramulla, Jammu and Kashmir, India

Date of Submission05-Jan-2022
Date of Decision04-Mar-2022
Date of Acceptance06-Mar-2022
Date of Web Publication1-Sep-2022

Correspondence Address:
Nissar Ahmad Shah
Registrar, Department of Orthopaedics, GMC, Baramulla, Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_2_22

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  Abstract 


Background: Plate fixation with bone grafting is the treatment of choice for nonunion of the clavicle and the use of precontoured locking compression plate (LCP) has been proposed to have an advantage of minimal hardware prominence and low rate of implant removal surgery. Materials and Methods: The retrospective analysis was performed to assess the long-term efficacy of precontoured LCP and bone grafting in nonunion of the clavicle. Fifteen patients who had undergone the surgery were assessed retrospectively in terms of clinical and radiological outcome for 4.1 years (range 2–7 years). The outcome was assessed using clinical and functional assessment by QuickDASH scoring and visual analog scale (VAS) system, radiological assessment in terms of union, time of return to previous activities, and any adverse results during the surgery or in the postoperative follow-up. Results: The radiological consolidation was achieved in all patients in a mean period of 18 weeks (range14–20 weeks). All patients returned to their previous activity level in a mean period of 5.9 months (range 2.5–9 months). There was a statistically significant improvement in QuickDASH and VAS scores (P < 0.05); however, one patient had symptomatic hardware prominence. Conclusion: The use of precontoured LCP in nonunion clavicle is a well-tolerated surgery giving promising results with most patients returning to previous activity level with the advantage of minimal hardware prominence and low rate of implant removal surgery.

Keywords: Clavicle, locking compression plate, nonunion, precontoured, QuickDASH


How to cite this article:
Shah NA, Dar NA, Rashid BA. Nonunion of clavicle treated with precontoured locking compression plate fixation and bone grafting: A long-term outcome. J Orthop Dis Traumatol 2022;5:128-31

How to cite this URL:
Shah NA, Dar NA, Rashid BA. Nonunion of clavicle treated with precontoured locking compression plate fixation and bone grafting: A long-term outcome. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Dec 3];5:128-31. Available from: https://jodt.org/text.asp?2022/5/3/128/355241




  Introduction Top


Clavicle fractures contribute to 5%–10% of adult skeletal trauma.[1] The incidence of nonunion of these fractures is 0.4%–4% though literature suggests the incidence of nonunion with nonoperative treatment of displaced clavicle fractures approaching 15% or even higher.[2],[3],[4],[5] Nonunion of the clavicle is symptomatic enough to warrant surgical intervention. Various fixation methods have been advocated like external fixation, intramedullary pinning, semi-tubular plate, Dynamic compression plate (DCP), reconstruction plate, and precontoured locking compression plates (LCPs).[6],[7],[8],[9],[10],[11],[12],[13] Plating has the added advantage of providing adequate rotational stability and maintaining the length of the clavicle. The precontoured LCPs are designed to fit the anatomic shape of the natural clavicle, eliminating the need for plate contouring at the time of surgery, potentially decreasing the risk of plate fatigue fracture, less hardware prominence, and decreased implant removal rate.[14],[15],[16],[17] Many authors advocate of the use of bone graft in the treatment of nonunion of clavicle fractures, although several studies have achieved union even without bone grafting.[18],[19],[20],[21] The objective of our study was to evaluate the clinico-radiological outcome of the patients having nonunion of clavicle managed by open reduction, internal fixation, and corticocancellous grafting using precontoured LCP.


  Materials and Methods Top


The retrospective study was conducted on 15 patients having nonunion clavicle who had undergone open reduction and internal fixation with bone grafting using superiorly placed precontoured LCP. Our main indications for the surgery were pain, limitation of activity, and instability at the fracture site. Our inclusion criteria were a symptomatic clavicular nonunion and exclusion criteria were the following: clavicular nonunion lasting <6 months, no functional shoulder impairment and pain, infected nonunions, tumors, or pathologic fractures, revision surgeries, patients with compromised immune systems. All patients had normal neurovascular status. In our study, 11 patients were male and four patients were female with a mean age of 33.2 years (range 22–48 years). The right side (dominant side) was involved in nine patients and the left side in six patients. The mean interval from injury to surgery was 9.4 months (range 4.1–14 months). All patients were operated on by a single senior surgeon during 2014–2019 in our hospital. Patients were operated on under general anesthesia and graft was taken from the iliac crest. The extremity was placed in a sling for immobilization, and gradual active-assisted range of motion was started within 1 week as tolerated. The patients were followed up regularly until the union was achieved, as determined by clinical examination and radiographic assessment. The outcome was assessed using clinical and functional assessment by QuickDASH scoring and visual analog scale (VAS) system, radiological assessment in terms of union, time of return to previous activities and any adverse results during the surgery or in the postoperative follow-up.[22],[23]


  Results Top


The mean follow-up in our study was 4.1 years (range 2–7 years). All the 15 patients progressed to the radiological union within a mean period of 18 weeks (range14–20 weeks) [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]. All patients returned to their previous activity level in a mean period of 5.9 months (range 2.5–9 months). There were no intraoperative complications. Two patients had stitch infection which was managed with dressings and antibiotics. Two patients described numbness around the incision. One patient had symptomatic hardware prominence but did not agree for implant removal. The comparison in the clinical scoring was made using Students t test, and P < 0.05 was considered statistically significant. The mean preoperative and postoperative Quick DASH Score was 48.58 ± 9.8 and 8.14 ± 4.8, respectively, which was statistically significant (P < 0.05). The mean preoperative and postoperative VAS score was 6.1 ± 1.3 and 0.8 ± 0.6, respectively, which was statistically significant (P < 0.05) [Table 1].
Figure 1: Non Union Clavicle (Case 1)

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Figure 2: Immediate post-op (Case 1)

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Figure 3: United Fracture Clavicle (Case1)

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Figure 4: Non Union Clavicle (Case 2)

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Figure 5: United Fracture Clavicle (Case 2)

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Table 1: Comparison of quick disabilities of the arm, shoulder, and hand and Visual Analog Scale scoring

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  Discussion Top


The clavicle has a pivotal role in the biomechanical function of the pectoral girdle and also the function of the upper limb.[24] Given this importance, much interest has been focused on the optimal method of treatment for patients with clavicular nonunion. Several factors have been proposed to predispose to the development of a clavicular nonunion like displaced fractures with initial shortening greater than two centimeters, comminuted or open fractures, inadequate immobilization, and refracture.[10],[11],[25] Patients with nonunion clavicle generally complain of pain, shoulder mobility impairment, cosmetic deformity, and neurovascular symptoms by compression of the subclavian vessels and/or brachial plexus.[6],[26] Various methods of fixation have been advocated for the treatment of nonunion of clavicle like intramedullary wires, external fixation, plates, and screws. Plates have the added advantage of giving rotational stability and maintaining the length of the clavicle. Various plates are being used like semi-tubular plates, dynamic compression plate, reconstruction plate, and precontoured LCP. Literature supports plate fixation with bone grafting as the most reliable technique.[27],[28],[29]

In our study, all patients achieved radiological union within 6 months of postoperative period and without any intraoperative complication. Faraud et al. concluded that treatment of middle-third clavicle nonunion after the initial failure of conservative treatment with stable fixation and bone graft is a reliable, well-suited, and effective treatment.[20] Similar to our current study findings, Laursen and Dossing yielded a high rate of healing and an acceptable functional outcome in patients with clavicular nonunions treated with compression plate and autologous cancellous bone graft.[18] Plates placed on the superior surface of the clavicle functions as tension bands since most nonunions have an apex directed superiorly. The precontoured LCPs are designed to fit the anatomic shape of the natural clavicle, eliminating the need for plate contouring at the time of surgery, potentially decreasing the risk of plate fatigue fracture and having less hardware prominence.[14],[15] In a comparison of dynamic compression plating (DCP) in 16 patients and low-contact dynamic compression plating (LC-DCP) techniques in 17 patients, Kabak et al. reported that the use of LC-DCP is a more reliable treatment method than the use of the DCP because the LC-DCP has several technical advantages that make it an ideal implant for satisfying the unique anatomic and biomechanical requirements of the internal fixation of clavicular nonunion.[30] VanBeek et al. in their retrospective study compared the noncontoured and precontoured plating in clavicle fractures and found significantly reduced hardware prominence and much lower reoperation rate for implant removal in precontoured group as compared to noncontoured group.[31] In our study, one patient had symptomatic hardware prominence, but he refused for implant removal surgery. Plate fixation needs broad exposure posing risk to the neurovascular structures around the bone, especially the supraclavicular sensory nerve. Endrizzi et al. in their study of 47 patients managed with plate fixation, 13% had a notable area of numbness on the anterior chest wall distal to the surgical site.[32] In our study, two patients (13.3%) had numbness around the surgical site. Our study of 15 patients having nonunion of clavicle had relief in pain and improved movement of the upper limb with statistically significant improvement in both Quick DASH and VAS scores. All patients returned to their previous activity level with no major complications. There are several limitations to our study. First, the design of the study is retrospective and we relied on patient records in collecting the data for the study variables. Second, the number of patients in our study was less because of the low frequency of precontoured LCP fixation at our institution in the past decade.


  Conclusion Top


Nonunion of the clavicle often results in a substantial residual disability of the injured extremity due to pain at the site and altered shoulder mechanics. Open reduction, internal fixation with precontoured LCP, and bone grafting is a well-tolerated surgery giving promising results with most patients returning to their previous activity level with the advantage of minimal hardware prominence and low rate of implant removal surgery.

Source of support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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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.  Back to cited text no. 4
    
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Kirchhoff C, Banke IJ, Beirer M, Imhoff AB, Biberthaler P. Operative management of clavicular non-union: Iliac crest bone graft and anatomic locking compression plate. Oper Orthop Traumatol 2013;25:483-98.  Back to cited text no. 16
    
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Schnetzke M, Morbitzer C, Aytac S, Erhardt M, Frank C, Muenzberg M, et al. Additional bone graft accelerates healing of clavicle non-unions and improves long-term results after 8.9 years: A retrospective study. J Orthop Surg Res 2015;10:2.  Back to cited text no. 19
    
20.
Faraud A, Bonnevialle N, Allavena C, Nouaille Degorce H, Bonnevialle P, Mansat P. Outcomes from surgical treatment of middle-third clavicle fractures non-union in adults: A series of 21 cases. Orthop Traumatol Surg Res 2014;100:171-6.  Back to cited text no. 20
    
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23.
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28.
Stufkens SA, Kloen P. Treatment of midshaft clavicular delayed and non-unions with anteroinferior locking compression plating. Arch Orthop Trauma Surg 2010;130:159-64.  Back to cited text no. 28
    
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30.
Kabak S, Halici M, Tuncel M, Avsarogullari L, Karaoglu S. Treatment of midclavicular nonunion: Comparison of dynamic compression plating and low-contact dynamic compression plating techniques. J Shoulder Elbow Surg 2004;13:396-403.  Back to cited text no. 30
    
31.
VanBeek C, Boselli KJ, Cadet ER, Ahmad CS, Levine WN. Precontoured plating of clavicle fractures: Decreased hardware-related complications? Clin Orthop Relat Res 2011;469:3337-43.  Back to cited text no. 31
    
32.
Endrizzi DP, White RR, Babikian GM, Old AB. Nonunion of the clavicle treated with plate fixation: A review of forty-seven consecutive cases. J Shoulder Elbow Surg 2008;17:951-3.  Back to cited text no. 32
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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