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Journal Club

July 2010

Open reduction and endobutton fixation of displaced fractures of the lateral end of the clavicle in younger patients.

• Authors: Robinson CM, Akhtar MA, Jenkins PJ, Sharpe T, Ray A, Olabi B.
  
• Institution: The Shoulder Injury Clinic New Royal Infirmary of Edinburgh, Edinburgh
  
• Journal: J Bone Joint Surg Br. 2010 Jun;92(6):811-6.

Abstract link

Introduction

• Displaced fractures of lateral 1/3 clavicle associated with high risk of non-union
• Failure to heal can lead to:
  
  • Persistent pain
    
  • Restricted ROM
    
  • Loss of strength
    
• Operation often indicated at 1° treatment for displaced fractures
• Operative options:
  
  • Coracoclavicular screws
    
  • Hook plates
    
  • Lateral clavicle plates
    
• Cx associated with implants:
  
  • Failure of metalware
    
  • Infection
    
  • Restriction of AC joint movement
    
• Aim
  
  • To assess in patients <60yrs undergoing operative intervention of lateral 1/3 clavicle fractures :
    
  • Functional outcome
    
  • Radiological outcome
    
  • Prevalence of complications

Methodology

• Inclusion criteria:
  
  • Medically fit patients <60yrs
    
  • <3wks from injury
    
  • Completely displaced fractures with no residual cortical contact
    
  • Located in portion of clavicle lateral to vertical line drawn up from base of coracoid
    
• Patients
  • 16pts with displaced fractures of lateral 1/3 clavicle
  • Mean age 38.3 (range 15 to 56)
    
  • All male
    
  • No open fractures
  • No pre-op neurovasc compromise
    
  • No associated fractures of scapula or proximal humerus
    
  • 2pts minor head injuries
    
  • 5pts ipsilateral rib fractures
• Pre op XRs:
  
  • AP
    
  • Axillary lateral
    
• Classification systems:
  • Neer, Edinburgh
    
• Operative Technique
  
  • Beach chair
    
  • Mean 6 days post injury (2 to 15)
    
  • Mean duration of surgery 40mins (30 to 75)
    
  • 6cm vertical incision with base centred on coracoid process
    
  • Deltotrapezius fascia incised perpendicular to incision and released from coracoid
    
  • Bone tunnels drilled in clavicle with 4.5mm cannulated drill:
    
    • Clavicle
      • 15mm medial to fractures site
        
    • Coracoid
      • Centred in coracoid, 20mm from tip
        
      • created under direct vision by splitting deltoid to reduce risk of eccentric tunnel placement:
        
      • Drilled perpendicular to superomedial surface of coracoid between 30° to 45° to coronal plane
        
  • Endobutton construct: 2 Endobuttons with #2 Orthocord
    
  • Core suture looped twice through the buttons:
    
    • Creates 6-ply sliding pulley effect
      
  • Lower button is passed through clavicle and coracoid:
    
  • Toggled on undersurface of coracoid
    
  • Reduced under direct vision and suture tensioned
    
  • Accurate reduction and toggling of lower endobutton confirmed with II
    
  • Suture ends tied over proximal endobutton
    
• Postop
• Sling 4/52 post op
  
• Physio commenced 4/52 post op:
  
  • Continued until full ROM achieved

Results

• Complications:
  
  • No early post op complications
  • No pt required further surgery
    
  • 1pt developed fibrous non-union:
    
    • No XR evidence of loss of reduction or displacement of endobutton
      
    • No pain or functional deficit
      
    • Not willing for further surgery
      
    • Remains asymptomatic 2yrs post op
  • 1pt shoulder stiffness 3/52 after R/O sling
    
    • Loss of ER 20° and Abd 20°
      
    • Regained full ROM 3/12 post op with physio
      
• Functional Outcome:
  
  • DASH and Constant score signif improved after 6 months
    
  • No statistically signif difference at 6 to 12 months
    
  • At 1yr: 15pts no pain,1pt mild pain
    
• Functional Outcome:
  
  • No RC weakness or impingement
    
  • No signs GH joint instability
    
  • No AC joint symptoms
    
  • 13pts sedentary jobs returned by 3 months
    
  • 3pts manual workers returned by 6 months
    
• Radiological Outcome:
  
  • Mean initial displacement 20mm (18-25mm)
    
  • Mean residual post op displacement 1mm
    
  • No failures of fixation
    
  • No loss of reduction in 1st yr post op
    
  • 15 patients radiological union
    
  • 1 pt fibrous non-union

Discussion

• Advantages:
  
  • One operation
    
  • No prominent metalware
    
  • Minimally invasive option
    
• Disadvantages:
  
  • Technically difficult to place bone tunnels centrally
    
  • Eccentric tunnel placement can cause implant cut-out and failure

Pros of Study

• Multiple modes of outcome assessment
  
• Trialled different variations of their own technique

Cons of Study

• Small series
  
• No direct comparison to other forms of treatment