w w w . r b o . o r g . b r
Original
article
Evaluation
of
the
results
from
surgical
treatment
of
fractures
of
the
lateral
extremity
of
the
clavicle,
using
the
double
ligature
technique
夽
Alberto
Naoki
Miyazaki,
Luciana
Andrade
da
Silva
∗,
Guilhermel
do
Val
Sella,
Sergio
Luiz
Checchia,
Sílvia
Helena
Cavadinha
Cândido
dos
Santos,
Vitor
Schneider
Chadud
FaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo(FCMSCSP),SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received17April2014 Accepted24April2014
Availableonline26February2015
Keywords:
Bonefractures Clavicle
Acromioclavicularjoint
a
b
s
t
r
a
c
t
Objective:Toevaluatetheincidenceofconsolidationinsurgicaltreatmentoffracturesof thelateralextremityoftheclavicleusingthedoublesubcoracoidligaturetechnique,with nonabsorbableNo.5thread.
Methods:BetweenMay1993andJune2013,theShoulderandElbowGroupofourservice surgicallytreated 116patients(116shoulders)withfracturesofthelateralextremityof theclavicle.Amongthese,wewereabletoreassess65cases.Thesurgicaltechniqueused consistedofdoublesubcoracoidligaturewithtwononabsorbablethreads.Intwopatients classifiedastypeIII,wehadtocombinethistechniquewithuseofaninterfragmentary screwforfixationoftheintra-articularportionoftheacromioclavicularjoint.
Results:Weachievedfractureconsolidationin90%.Fourteencases(21%)evolvedwithmajor complications:fourcasesofpseudarthrosis,fiveofadhesivecapsulitis,twoofdelayed con-solidationandthreeoflossofreduction.Twocases(3%)evolvedwithminorcomplications ofskingranuloma.
Conclusion:Thedoubleligaturetechniqueforfracturesofthelateralextremityoftheclavicle promotesthestabilizationneededforconsolidationtotakeplace,withouttheneedfor synthesisusingmetalcomponents.Itavoidsreoperationforthesynthesismaterialtobe removed.Moreover,itisalow-costprocedurewithgoodreproducibilityandpreservationof theacromioclavicularjoint.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
夽
WorkdevelopedintheShoulderandElbowGroup,DepartmentofOrthopedicsandTraumatology,FaculdadedeCiênciasMédicasda SantaCasadeSãoPaulo(FCMSCSP),PavilhãoFernandinhoSimonsen,SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:lucalu01@me.com(L.A.daSilva).
http://dx.doi.org/10.1016/j.rboe.2015.02.008
Avaliac¸ão
dos
resultados
do
tratamento
cirúrgico
das
fraturas
da
extremidade
lateral
da
clavícula
pela
técnica
do
amarrilho
duplo
Palavras-chave:
Fraturasósseas Clavícula
Articulac¸ãoacromioclavicular
r
e
s
u
m
o
Objetivo: Avaliara incidênciadeconsolidac¸ão dotratamentocirúrgico nasfraturasda extremidadelateraldaclavículapelatécnicadoduploamarrilhosubcoracóideocomouso defioinabsorvívelnúmero5.
Métodos:Entremaiode1993ejunhode2013,oGrupodeOmbroeCotovelodonossoservic¸o tratoucirurgicamente116pacientes(116ombros)comfraturadaextremidadelateralda clavícula.Desses,conseguimosreavaliar65.Atécnicacirúrgicausadafoioamarrilhoduplo subcoracóideocomdoisfiosinabsorvíveis.EmdoispacientesclassificadoscomotipoIII tivemosdeassociarumparafusointerfragmentárioparafixac¸ãodaporc¸ãointra-articular daAC.
Resultados: Tivemos 90% de consolidac¸ão da fratura; 14 casos (21%) evoluíram com complicac¸õesmaiores:quatropseudoartroses,cincocapsulitesadesivas,doisretardosde consolidac¸ãoetrêsperdasdereduc¸ão;edoiscasos(3%)evoluíramcomcomplicac¸ãomenor: granulomadepele.
Conclusão:Atécnicadoamarrilhoduploparaasfraturasdaextremidadelateraldaclavícula promoveaestabilizac¸ãonecessáriaparaquehajaconsolidac¸ãosemnecessidadede sín-tese metálica;evitareoperac¸ões pararetirada domaterial de síntese; além deserum procedimento de baixo custo,com boareprodutibilidade e preservac¸ão da articulac¸ão acromioclavicular.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Allman divided fractures of the clavicle into three groups basedonanatomyandinjurymechanisms.1Fractureslocated in the middle third (group I) are the most frequent type, accountforaround 80%ofthecasesand especiallyamong young adults. Fractures located at the lateral extremity of theclavicle(groupII)accountforaround15–25%,whileonly around5%occurintheproximalthird(groupIII).2–4Fractures ofthelateralextremityoftheclavicleareclassifiedbasedon whetherthecoracoclavicularligamentsareintactandonthe impairmentoftheacromioclavicularjoint.Thisclassification wasfirst describedbyNeer andwas subsequently comple-mentedbyCraig.5,6
AccordingtoEdwardsetal.7andAnderson,8surgical treat-mentisindicatedinsituationsofdisplacedfracturesofthe lateralextremity ofthe claviclebecauseofthehigh riskof non-consolidation, which may affect around 30% ofthese patients.Thismorbidityisattributedpartlytotheshearing forcesbetweenthefragments,whichcontributestoward non-consolidationofthefracture.9
Thereisno standardizedmethodforsurgicaltreatment offractures ofthe lateralextremity fthe clavicle.10 Several techniqueshavebeendescribedintheliterature,consisting ofusingascrew,11fixationwithmetalwires,12,13fixationwith ahookplate,14fixationwithaspecificlockingPlate15oruseof cerclage.10,16AccordingtoNeer,16thecerclagetechniquewith doublebindingbetweentheclavicleandthecoracoidprocess indirectlypromotesreductionand stabilization ofthe frac-ture,withminimalperiostealinjury.Onceconsolidationhas beenachieved,theacromioclavicularligaments(especiallythe
upperone)aresufficientformaintainingthesuspensor mech-anismoftheshoulder.11,16,17
Thepresentstudyhadtheaimofevaluatingtheincidence ofconsolidationfollowingsurgicaltreatmentbymeansofthe subcoracoiddouble-bindingtechnique,usingnonabsorbable No.5thread,incasesoffracturesofthelateralextremityof theclavicle.
Sample
and
methods
Between May 1993and June 2013,116 patients(116 shoul-ders) withfractures ofthe lateral extremity ofthe clavicle were treatedsurgicallybythe shoulderand elbowgroupof ourservice.Amongthesepatients,93underwentthe double-binding technique. We were able to reassess 65 of these patients from their medical files and radiographic images
(Table1).
Theinclusioncriterionwasthatallthepatientsneededto havepresentedfracturesofthelateralextremityoftheclavicle andneededtohaveundergonesurgicaltreatmentbymeans ofthedouble-bindingtechnique,withpostoperativefollow-up foraminimumofsixmonths.
Patientspresentingthefollowingwereexcluded:fractures ofthemiddleorproximalthirdsoftheclavicle;fracturesin diseasedbones;previousinjuriesorfacturesoftheshoulderor theipsilateralupperlimb;associatedneurovascularinjuries; orfollow-upshorterthanwhatwasestablished.
Table1–Generaldataonthepatientswithfracturesofthelateralextremityoftheclaviclewhounderwentthe double-bindingtechnique.
Sex Age Dom. Class T TM Cons. FU Surgery
M=50(77%) 14–83 D=37(57%) II=42(65%) 1–19 HE=48(74%) C=59(90.7%) 3–180 Cerclagealone=63(97%)
mn=37.7 mn=7.6 mn=11.6 IFS=2(3%)
F=15(23%) ND=28(43%) III=06(9%) LE=17(26%) NC=06(9.3%) IV=01(1.5%)
V=16(24.5%)
M,male; F,female;age,in years;mn,mean;Dom., dominance;D,dominant;ND,non-dominant;Class,classification;T,timeinterval betweentraumaandsurgeryindays;TM,traumamechanism:HE,highenergy;LE,lowenergy;Cons.,consolidation;C,consolidated;NC, non-consolidated;FU,lengthoffollow-upinmonths;IFS,associationwithinterfragmentaryscrew.
Thepatients’agesrangedfrom14to83years(meanof37.7). There were 50 malepatients (77%) and 15female patients (23%). The dominant limb was affected in 37 cases (57%)
(Table1).
Inrelationtothetraumamechanism,74%(48cases)were duetohigh-energytraumaand26%(17cases)tolow-energy trauma(Table1).
UsingtheCraigclassification,thepatientsweregroupedas follows:42casesoftypeII(65%),sixoftypeIII(9%),oneoftype IV(1%)and16oftypeV(25%)(Table1).
Thesurgicalprocedurewasperformedwiththepatientin thedeckchairposition.Weusedasaber-cutincisionlocated mediallytothe fracture line.Weopened thedeltotrapezial fasciatoexposethefocusofthefractureandthecoracoid pro-cess,withoutviewingtheacromioclavicularjoint.Wemadea centralorificeintheclavicle,2cmmediallytothefracture. Wepassedtwononabsorbableno.5threadsunderthe cora-coidprocessandthroughthisorifice.Wereducedthefracture bymeansofamaneuvertolowertheproximalportionofthe clavicleandthesuspensionofthelateralextremityofthe clav-icle,withcompressionoftheipsilateralelbow,andthentied thethreadsseparatelytotheclavicle(Fig.1).Theknotswere directedtoward thecoracoidprocess so astoavoidbulges undertheskin.Intwopatientswhowereclassifiedastype III,wehadtouseaninterfragmentaryscrewinassociation withthisprocedure,toachievefixationoftheintra-articular portionoftheacromioclavicularjoint(Fig.2).
Duringthepostoperativeperiod,thepatientswere immo-bilized until fracture consolidation had been achieved (approximatelysix toeight weeks).During this period,the onlymovementsallowedwerelateralrotationoftheshoulder andflexion-extensionofthe elbowwiththearmalongside thetrunk.Afterconsolidationhadbeenconfirmed radiogra-phically,thepatientswereallowedtomakemovementsinall planesandtograduallyreturntotheirusualactivities.Allthe patientswereevaluatedradiographicallyduringthe postop-erativeperiod.
Descriptiveanalysis wasperformed byconstructing fre-quencytablesandgraphsshowingthedata.Sincethesample resultedingroupsforeachvariableofinterestthatwereofvery smallsize,onlynonparametrichypothesis testswereused, withasignificancelevelof5%.Thus,hypothesesforwhich thetestspresentedadescriptivelevel(p-value)lowerthan0.05 wererejected.
Totesttheindependencebetweenpairsofrandom vari-ables, the Fisher test was used, based on hypergeometric
distribution.Totestwhethertherewasanydifferencebetween the means ofpairs ofgroups, the Mann–Whitneytest was used.Totesttheequalitybetweenmorethan threemeans, Kruskal–Wallisanalysiswasused.Theanalysiswasdonewith theaidoftheMinitab®statisticalsoftware,version16.
This study was approved by our institution’s research ethicscommittee,underno.14312013.0.0000.5479.
Results
Wefoundthatconsolidationofthe lateralextremityofthe clavicleoccurredin59ofthe65cases(90%).
Becauseofthesmallnumberofpatientsinwhom consol-idationofthefracturedidnotoccur,distributedbetweenthe differentsubgroupsoftheclassification,itwasnotpossible toperformedindependencetestsbetweentheconsolidation andclassificationvariables.However,inobservingthe propor-tionsofthisoccurrence,wenotedthatamongallthefractures thatdidnotconsolidate,67%(11)wereoftypeIIand33%(four) wereoftypeV.Amongthosethatconsolidated,64%(31)were
oftypeIIand24%(12)wereoftypeV(Table1).
The total number of complications was 16 (24%). We dividedthecomplicationsintomajorandminortypes.They wereconsideredtobemajoriftheyinfluencedthefunctional result.Therewere14cases(21%)ofmajorcomplications:four withpseudarthrosis,fivewithadhesivecapsulitis,twowith delayedconsolidationandthreewithlossofreduction.There werealsotwocases(3%)ofminorcomplications,consistingof skingranuloma(Table2).
In the statistical analysis, we were unable to detect any relationshipbetweenthe traumamechanismand con-solidation (p=0.648) or between sex and consolidation (p=1.000). There were also no statistically significant dif-ferences betweenthe means forthetimeinterval between
Table2–Descriptionofthecomplications.
Adhesivecapsulitis 5(31.2%)
Granuloma 2(12.5%)
Delayedconsolidation 2(12.5%)
Lossofreduction 3(18.8%)
Pseudarthrosis 4(25%)
Fig.1–(A)Illustrationdemonstratingfractureofthelateralextremityoftheclavicle;(B)radiographicimageoftheleft shoulder,inZancaview,showingfractureofthelateralextremityoftheclavicle;(C)illustrationofthesurgicaltechniqueof doublebinding;(D)radiographicimageoftheleftshoulder,inZancaview,showingconsolidationofthefractureafter binding.
traumaandsurgery,foranyofthefollowingpairsofgroups: withandwithoutconsolidation(withconsolidation,7.8days, versuswithoutconsolidation,5.3days;p=0.351);orwithand withoutcomplications(withcomplications,6.2days,versus withoutcomplications,8.1days;p=0.313).
Therewerestatisticallysignificantdifferencesbetweenthe meansforages,forthefollowingpairs ofgroups:withand without consolidation (with consolidation, 36.3 years, ver-suswithoutconsolidation,51.3years;p=0.048);andwithand withoutcomplications(withcomplications,45.7years,versus withoutcomplications, 35.1years;p=0.011).Theageswere greaterwhentherewasnoconsolidationandwhentherewere complications.
Discussion
Reconstructionofthesuspensormechanismoftheshoulder can be done directly, bymeans ofosteosynthesis between thebonefragments,5,14,15,18–20orindirectly,bymeansof syn-thesisbetweentheclavicleandthecoracoidprocess,either usingascrew11 orusingcerclage.10,16 Therearealso differ-ent techniques in relation to the access route, which can be for either open or arthroscopic procedures.21,22 These techniques bring together the bone fragments and enable fracture consolidation. After this has been achieved, the acromioclavicular ligaments (especially the upper one) are
Fig.3–Radiographicimagesoftheleftshoulder.(A)Fractureofthelateralextremityoftheclavicle;(B)non-consolidation afterinitialsurgicaltreatmentusingdoublebinding;(C)consolidationofthefractureaftersecondprocedureusinglocking plate.
sufficientformaintainingthesuspensormechanism ofthe shoulder.11,16,17
Thevarioussurgicaltechniquesfortreatingfracturesofthe lateralextremityoftheclaviclearenotfreefrompost-surgical complications.LeppilahtiandJalovaarareportedthatthe tech-niquethatusesfixationwithmetalwiresisassociatedwith migrationofthewireandinfectionofthepinpathway.12Shin etal.13reportedthattheclavicleunderwenterosioncausedby thesuturingmaterial,duringthereconstructionofthe coraco-clavicularligamentsin11%ofthecases.Thesecomplications werenotobservedinoursample.
Kleinetal.14observedthatwiththehookplatetechnique, despitepositiveresultsregardingboneconsolidation(94.7%) and patientrehabilitation,complicationsoccurred in15.8% ofthecasesandcomprisedinfections,fracturingaroundthe implant and failure of the synthesis material. This made it necessaryto performa second procedure toremovethe implants,sothatthesubacromialimpactandriskoffracturing theacromionwouldbereduced.
Andersenetal.15retrospectivelyevaluated16patientswho hadundergonefixationbymeansofalockingplaceforthe lateralextremityoftheclavicleandfoundthatthe consolida-tionratewas94%.Theyreportedthatthereweretwocases ofcomplications:oneofinfectedpseudarthrosisandoneof fracturingaroundtheimplant.
With regard to other fixation methods described previ-ously,wedidnotseeanyreasontousethem,giventhatthe double-bindingtechniqueissimplerandcheaper,hasfewer complicationsand does notrequire a second procedure to removethesynthesismaterial.
Yang et al.10 conducted a retrospective study in which thetechnique appliedwassimilar tothatused amongour patients, but with bands of nonabsorbable material and withoutperformingligamentrepairorusingimplants.They showed a consolidation rate of 100% (29 patients). How-ever, somecasesofcomplicationswere observed:adhesive capsulitis(one case) anddiscomfort onthe skincausedby bulgingofthe suturingknot (one case).Wehad complica-tionssimilartothoseofYangetal.10Fivepatientspresented adhesivecapsulitisandunderwentconservativetreatmentby means ofserial blocksofthe suprascapularnerve.23 These patientsevolvedwithconsolidationofthefracture.Another two patients evolvedwith superficial granuloma and were
treatedsatisfactorilybymeansofcleaning,debridementand removalofthesuturingthreadfromtheskin.
Thetwopatientswhoevolvedwithdelayedconsolidation didnotrequireanyothersurgicalprocedure.Theyevolvedto fractureconsolidationwithin10monthsandreachedanormal rangeofmotion,inrelationtotheircontralateralside.
Inthethreecasesinwhichtherewaslossofreduction,one ofthemconsolidatedsatisfactorily,despiteskewed consoli-dationofthefragments,whiletheothertwohadtoundergo a secondprocedure, 15 daysand onemonthafterthe first surgery. These cases required new binding, performed in associationwithfixationbymeansofKirschnerwires.They evolvedwithconsolidationofthefractureandgoodrangeof motion.
In our sample,10% of the casesdid notattain fracture consolidation(fourpatients).Oneofthesepatientspresented clinicalasymptomaticpseudarthrosisanditwasdecidedto simplymonitorthepatient:agoodfunctionalresultwasseen. Threepatientsunderwentasecondsurgicalprocedure.Oneof themreceivedalockingplateforthelateralextremityofthe clavicle,inassociationwithabonegraft.Anothercaseonly receivedalockingplateforthelateralextremityofthe clavi-cle(Fig.3).Thethirdcasewastreatedusingacombinationof aKirschnerwireandabonegraft.Thesereoperatedpatients achievedfractureconsolidation,withgoodfunctionalresults. Outofthe19patientsevaluatedbyShinetal.,13onlyone(5%) evolvedwithsymptomaticpseudarthrosis.Thispatient sub-sequentlyunderwentresectionofthedistalfragmentofthe fracture.
Weobserved that theyounger patients had fewer com-plications and that their fractures consolidated better, in comparisonwiththeolderpatients.Thisresultmayhavebeen duetothebonequalityandbetterformationofbonecallus.
Conclusion
Weachievedaconsolidationrateof90%through usingthe double-bindingtechniqueforcasesoffracturesofthelateral extremityoftheclavicle.
double-bindingtechnique,withgreatermeanageinthecases withoutconsolidation(51.3years).
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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