Clavicle Fractures: Are You Kidding?!? Intermedullary Devices are - PowerPoint PPT Presentation

Clavicle Fractures: Are You Kidding?!? Intermedullary Devices are Far Better, Much Safer and Get the Results - What are You Reading? Smoking? Carl J. Basamania, MD, FACS Orthopedic Physician Associates Swedish Orthopaedic Institute Seattle, Washington

Presenter Disclosure Information Carl J. Basamania, MD, FACS Disclosure Information The following relationships exist: DePuy/Johnson and Johnson: Consultant, Royalties Zimmer/Biomet: Consultant, Royalties Sonoma Orthopaedics: Consultant, Royalties Invuity: Consultant, Stock Options BioPoly: Consultant, Stock Options Nothing of value received for this presentation No “off label” use of any products

40 yo female triathlete

“I broke my left clavicle 18 months ago – I hate that thing!”

Plate Complications • Painful, prominent hardware • Soft tissue stripping • Non-cosmetic scar • Multiple stress risers – ? Permanent if > 33% of clavicle diameter • Nerve damage

Plate Complications • Vast majority of complications are implant related – irritation or failure of the plate being consistently reported on in almost every study, on average ranging from 9 to 64% • “ We conclude, based on the figures of plate debridement, removal or revision, that the incidence of major complications is high, ranging up to 64%” • Millet, et al. Arch Orthop Trauma Surg. 2012 May; 132(5): 617–625.

21 yo 3 years s/p plating “iatrogenesis imperfecta” Are you making the plate match the clavicle or the clavicle match the plate?

Post hardware removal fracture

Infection after Plate Fixation • Reports range from 0.4% - 7.8% • Bostman (1997): • – 5 deep, 3 superficial – 7.8% • Liu, et al (2008): – 7 of 142 – Average time to presentation: 28 days – 4.9% • Kaohsiung J Med Sci. 2008 Jan;24(1):45-9

Bad Plate

Vascular Injury • Vascular injury can occur due to the proximity of the subclavian vessels to the medial clavicle JBJS Case Connector, 2013 Mar 13;3(1):e24 1-4.

Intramedullary Fixation • IM fixation is not a new concept Intramedullary fixation with beef bone (Brockway, JBJS, 1930)

Types of IM fixation • Flexible –Titanium elastic nail • Rigid –Screws –Rockwood pin • Hybrid –Arthrex CRx

Intramedullary Fixation • Minimizes soft tissue dissection • Preservation of periosteal blood supply • Callus healing – faster and observable • Better resistance to repetitive bending • Ease of reduction – “If it’s IM – It’s anatomic!” • Minimal stress shielding – load sharing not sparing • Ease of hardware removal • Cosmetic incisions • Outpatient procedure

Strength During and After Fixation

Results • With the exception of the IM Removal group, all specimens failed significantly lower than the intact specimens. Energy (J) Torque (Nm)

Problems with IM Fixation • Painful, prominent hardware - #1 problem • Migration – smooth pins • Lack of length and rotational control • Static distraction (fully treaded pins, Herbert type screws)

Intramedullary Technique

IM vs Plate Fixation Author Source # of patients Technique Used Outcomes of Interest Failure rate Complication rate Comment Level of evidence Saha, et al Indian Journal of Orthopaedics 37 plate TEN Significantly shorter time 0% IM group Major complications: 14% 11% infection rate in plate I 2014;48(6):587-593. 34 IM Anterosuperior locking plate to union, operative time 3% in plate group plate vs group and blood loss in IM 0% IM 16% of plate patients rated group Minor complications: 16% their scar as ugly plate vs 38% in IM group Assobhi J Orthopaed Traumatol. 2011, 19 plate TEN Significantly shorter Nonunion: Major complication rate: 5.3% re-fracture rate in plate I 12:185–192 19 IM 3.5 recon plate hospital stay, length of 5.3% plate 15.8% plate vs 0% IM group after hardware surgery, scar length and 0% IM Minor complication rate: removal vs 0% in IM group blood loss in IM group 36.8% plate vs 21.1% IM Ferran, et al J Shoulder Elbow Surg. 2010, 17 IM Rockwood screw Mean Constant score: 0% both groups 24% in IM group vs 80% in Hardware removal: I 19: 783-789 15 plate 3.5 LCDCP 92.1 IM vs 88.7 plate plate group 100% planned removal in IM group 53% due to irritation and infection in plate group Bohme, et al Z Orthop Unfall. 2011, 20 IM TEN 4% infection rate in plate 0% nonunion in 15% IM Both operative groups had II Jan;149(1):68-76. 53 plate DCP, recon or LCDCP group operative groups 22% plate better pain relief, function 47 nonop and cosmetic result compared to nonop Chen, et al J Shoulder Elbow Surg. 2012, 84 plate TEN Significantly shorter time 2% IM Infection: 43% of plate group rated III 21(4): 495-501 57 IM Reconstruction plates to union, operative time 4% plate 2% IM results as unsatisfactory and less blood loss in IM 4% plate Hardware failure: compared to 14% in IM group 7%plate group 5% IM Wijdicks, et al International Orthopaedics 43 plate TEN 7% refracture rate in 14% implant failure 26% major complication 12% major revision plate vs III (SICOT). 2012 36:2139–2145 47 IM Reconstruction and locking plate group vs 0% IM plate vs plate vs 4% IM 2% IM plates 2.1% IM Wenninger, et al J Surgical Orthop Advances 29 plate Rockwood screw majority of 0% nonunions in both Complication rate: Active duty military III 22(1):77–81, 2013 33 IM 3.5 recon and precontoured symptoms were from the groups 31% plate vs 9% IM population plates pressure of body armor and rucksack wear during training Liu, et al Journal of Trauma Injury, 59 plate TEN Significantly shorter Nonnunion: Complication rate: Wound complication rate: III Infection, and Critical Care 51 IM Straight and contoured operative time, hospital 9.8% IM vs 39% IM vs 53% plate 5.9% IM vs 10.2% plate 2010, 69(6):E82-E87 superior plates stay, incision size and 10.2% plate blood loss in IM group Malunion: 7.8% IM vs 3.4% plate Kleweno, et al J Shoulder Elbow Surg. 2011, 18 IM Rockwood screw Average time to union: 0% IM group vs 7% 28% IM vs 36% plate 7% delayed union and 14% III 20, 1114-1117 14 plate 6 recon, 6 locking and 2 8 months IM vs 17 plate refracture rate in plate group precontoured plates months plate vs 0% IM group Thyagarajan, et al International J of Shoulder 17 IM Rockwood screw IM group had 100% IM 0% IM:12% superficial wound All patients in IM group III Surgery 2009;3(2):23-27 17 plate LCDCP plates union by 8-12 weeks. Plate 6% nonunion Plate: 12 % implant failure were satisfied with result. 17 nonop All IM surgeries Nonop 23.5% nonunion 35% plate irritation 24% scar 35% of plate group had pain outpatient. or malunion related pain with activity. 12% of IM Plate group all had 2-3 group had only mild pain day hospital stay Advanced Reconstruction: Shoulder 2, AAOS 2016

• Non-funded Level I PRCS • Shorter operative & fluoro times, hospital stay and time to union in hybrid group • Greater scar dissatisfaction in plating group

“intramedullary pin fixation is the optimum treatment method for displaced midshaft clavicle fracture because of the low probabilities of nonunion and infection” “Major re-intervention and re-fracture after implant removal occurred more frequently after plate fixation of non-comminuted, displaced midshaft clavicle fractures.”

• “Our results suggest that intramedullary nailing and plating provide equivalent long-term functional outcomes; however, plating may lead to a higher risk of treatment failure and nonoperative complications.” – Hussain, N. et al. Intramedullary Nailing Versus Plate Fixation for the Treatment Displaced Midshaft Clavicular Fractures: A Systematic Review and Meta-Analysis. Sci. Rep. 6 , 34912;doi:10.1038/srep34912 (2016).

3 months s/p IM fixation

s/p hardware removal with bone grafting of screw holes

3 months post implant removal Pain after light swimming

IM Fixation with 3mm device

4 months postop

What do you think your patients would prefer?

Or this

I rest my case