Perspective

Low nonunion rates associated with operatively treated clavicle fractures

Despite similar results seen after nonoperative and operative treatment of displaced distal clavicle fractures, operative treatment significantly lowered the rate of malunion and nonunion, according to a presentation in the Game Changers session at the American Academy of Orthopaedic Surgeons Annual Meeting.

“Surgery is a safe option for people with distal clavicle fractures,” Jeremy Hall, MD, FRCS(Ortho), assistant professor at St. Michael’s Hospital in Toronto and the University of Toronto, told Orthopedics Today. “[Surgery] works well, it gives good results, it gives restored anatomy of the clavicle and I think that is important for a number of people, especially people that have heavy and repetitive-type jobs or activities they like to do.”

Treatment types compared

Hall and his colleagues randomly assigned 57 patients with displaced distal clavicle fractures to undergo nonoperative treatment with a sling and early range of motion as tolerated (n=30) or operative treatment with plate fixation (n=27). The primary outcome was DASH scores at 1 year. Other outcome measures used were the Constant score, complications and how satisfied patients were with the appearance of their shoulders.

Researchers performed clinical and radiologic assessments at 2 weeks, 6 weeks, 3 months, 6 months and 1-year post-injury.

“In the end, there were no statistically significant differences in DASH between the operative and nonoperative groups at any time point,” Hall said at the meeting, noting Constant scores for both groups were also not statistically significantly different at any time point.

A significantly faster time to union was seen in the operative group. Union was seen in 95% of patients in the operative group vs. 42% of patients in the nonoperative group, he noted.

“Those with nonoperative managed fractures essentially had all the mal- or nonunions, which was significantly higher in the nonsurgical group,” Hall said.

Similarities to AC joint dislocation treatment

In the interview with Orthopedics Today, Hall said he was surprised by the similarities in the groups’ patient-related outcomes. He noted a study of displaced midshaft clavicle fractures by the Canadian Orthopaedic Trauma Society showed a difference between operative and nonoperative treatment, but another study by the same investigators showed no difference between operative and nonoperative treatment of acromioclavicular (AC) joint dislocations.

“It surprised me that these fractures of the clavicle behaved a little bit more like the AC joint injuries … than the midshaft clavicle fracture study for results,” Hall said. “… I thought for sure that there would be a better outcome with fixing these fractures than not.”

Following patients 2 years might help identify significant changes in function or whether patients needed further surgery or had additional injuries, according to Hall. Conducting a metaanalysis to determine patient and fracture characteristics that may be associated with further surgery may be beneficial, he said.

“There are a lot of different directions to take this study in the future, but … the easy ones are just to re-evaluate the information we have, following [patients] a little bit longer and maybe try to combine them with other studies,” Hall said. – by Casey Tingle

References:

Altamimi SA, et al. J Bone Joint Surg Am. 2008;doi:10.2106/JBJS.G.01336.

Canadian Orthopaedic Trauma Society. J Orthop Trauma. 2015;doi:10.1097/BOT.0000000000000437.

Hall J, et al. Paper 193-GC. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 6-10, 2018; New Orleans.

For more information:

Jeremy Hall, MD, FRCS (ORTHO), can be reached at 30 Bond St., Toronto, ON M5B 1W8, Canada; email: hallj@smh.ca.

Disclosure: Hall reports no relevant financial disclosures.

Despite similar results seen after nonoperative and operative treatment of displaced distal clavicle fractures, operative treatment significantly lowered the rate of malunion and nonunion, according to a presentation in the Game Changers session at the American Academy of Orthopaedic Surgeons Annual Meeting.

“Surgery is a safe option for people with distal clavicle fractures,” Jeremy Hall, MD, FRCS(Ortho), assistant professor at St. Michael’s Hospital in Toronto and the University of Toronto, told Orthopedics Today. “[Surgery] works well, it gives good results, it gives restored anatomy of the clavicle and I think that is important for a number of people, especially people that have heavy and repetitive-type jobs or activities they like to do.”

Treatment types compared

Hall and his colleagues randomly assigned 57 patients with displaced distal clavicle fractures to undergo nonoperative treatment with a sling and early range of motion as tolerated (n=30) or operative treatment with plate fixation (n=27). The primary outcome was DASH scores at 1 year. Other outcome measures used were the Constant score, complications and how satisfied patients were with the appearance of their shoulders.

Researchers performed clinical and radiologic assessments at 2 weeks, 6 weeks, 3 months, 6 months and 1-year post-injury.

“In the end, there were no statistically significant differences in DASH between the operative and nonoperative groups at any time point,” Hall said at the meeting, noting Constant scores for both groups were also not statistically significantly different at any time point.

A significantly faster time to union was seen in the operative group. Union was seen in 95% of patients in the operative group vs. 42% of patients in the nonoperative group, he noted.

“Those with nonoperative managed fractures essentially had all the mal- or nonunions, which was significantly higher in the nonsurgical group,” Hall said.

Similarities to AC joint dislocation treatment

In the interview with Orthopedics Today, Hall said he was surprised by the similarities in the groups’ patient-related outcomes. He noted a study of displaced midshaft clavicle fractures by the Canadian Orthopaedic Trauma Society showed a difference between operative and nonoperative treatment, but another study by the same investigators showed no difference between operative and nonoperative treatment of acromioclavicular (AC) joint dislocations.

“It surprised me that these fractures of the clavicle behaved a little bit more like the AC joint injuries … than the midshaft clavicle fracture study for results,” Hall said. “… I thought for sure that there would be a better outcome with fixing these fractures than not.”

Following patients 2 years might help identify significant changes in function or whether patients needed further surgery or had additional injuries, according to Hall. Conducting a metaanalysis to determine patient and fracture characteristics that may be associated with further surgery may be beneficial, he said.

“There are a lot of different directions to take this study in the future, but … the easy ones are just to re-evaluate the information we have, following [patients] a little bit longer and maybe try to combine them with other studies,” Hall said. – by Casey Tingle

References:

Altamimi SA, et al. J Bone Joint Surg Am. 2008;doi:10.2106/JBJS.G.01336.

Canadian Orthopaedic Trauma Society. J Orthop Trauma. 2015;doi:10.1097/BOT.0000000000000437.

Hall J, et al. Paper 193-GC. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 6-10, 2018; New Orleans.

For more information:

Jeremy Hall, MD, FRCS (ORTHO), can be reached at 30 Bond St., Toronto, ON M5B 1W8, Canada; email: hallj@smh.ca.

Disclosure: Hall reports no relevant financial disclosures.

    Perspective

    This is an important study in that it is the first to randomize treatment of displaced distal clavicle fractures into operative and nonoperative groups. The authors should be commended for their efforts. They demonstrate distal clavicle fractures are different from mid-shaft clavicle fractures in terms of treatment and outcomes and should not be approached in the same fashion. The results are not unexpected considering prior papers; despite a high nonunion rate (37%) in the nonoperative group, final clinical outcomes at 1 year are essentially the same. However, further investigation is warranted before the treating surgeon should conclude all displaced distal clavicle fractures should be treated nonoperatively. It is possible the DASH and Constant scores are not sensitive enough to detect functional differences in these patients. Further, seven (23%) of the 30 nonoperative patients went on to surgical intervention. Clearly, there exists a patient population that would benefit from early open reduction internal fixation and studies to help predict who will be among those patients would be helpful. One might assume older, inactive patients tolerate a nonunion better than younger more active patients. Only studies that drill down into these aspects will ultimately answer this question to guide the treating surgeon. However, this paper was a well-done first step to address this topic.

    • Julie Bishop, MD
    • Chief, division of shoulder surgery
      Professor of clinical orthopedics
      Ohio State University Wexner Medical Center
      Columbus, Ohio

    Disclosures: Bishop reports she is a board or committee member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic Association and the American Shoulder and Elbow Surgeons.

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