Additional bone graft accelerates healing of clavicle non-unions and improves long-term results after 8.9 years: a retrospective study

Abstract

BackgroundClavicle non-unions can occur after both conservative and operative treatment failure. Here, we investigated the outcome of patients with delayed fracture healing or non-unions of the clavicle. Patients underwent revision surgery by plate osteosynthesis of the clavicle with or without bone grafting. Our aim was to determine rates of bone healing and the functional long-term outcome.MethodsThe study population of 58 consecutive patients was divided into group 1 (n = 25; no bone graft) and group 2 (n = 33; iliac crest bone graft). Bone consolidation was determined by the Lane-Sandhu score preoperatively and after 2.2 ± 1.8 years, respectively. The functional long-term outcome was determined after 8.9 ± 2.7 years in all available patients (n = 30) by the Constant score, DASH (Disabilities of the Arm, Shoulder and Hand) score and SF-36, and clavicle length was measured by ultrasound as compared to the healthy side.ResultsClavicle consolidation was achieved in 54 out of 58 patients (93.1%) after revision surgeries. The radiographic score and bone consolidation rates were significantly higher in group 2 (93.3%) as compared with 72% in group 1 (p = 0.02), resulting in a significantly shorter time to bone consolidation in group 2. Similarly, the relative risk for additional surgery after the first revision surgery was 4.7-fold higher in group 1 (p = 0.02). The long-term results showed overall very good results in DASH score (14.9 ± 16.5) and good results in Constant scores (77.9 ± 19.9). The group analyses found significantly better Constant scores and better visual analogue pain scale (VAS) numbers in group 2. Clavicle shortening appeared to affect the clinical results, and a mild correlation between shortening and Constant scores (R = −0.31) was found.ConclusionsThis study shows high rates of bone healing and good functional outcomes after surgical revision of clavicle non-unions and further demonstrates that additional bone graft could significantly accelerate bone healing. This indicates that revision surgery of clavicle non-unions might preferably be done with additional bone graft, even if the surgeon considers that bone healing might be achieved without bone grafting.

A Prospective Study of Fracture Nonunion of Clavicle Managed by Internal Fixation With or Without Bone Grafting

“…6 Neer described nonunion rates of 0.1% after conservative treatment and 4.4% after operative treatment. 1 Several factors predispose to nonunion of the clavicle like inadequate conservative treatment and immobilisation, severity of trauma and fracture comminution 7,8 , re-fracture, distal-third fracture 1,9 , marked displacement or shortening of >2 cms, soft-tissue interposition, and primary open reduction. 10,11 Nonunion can be either atrophic or hypertrophic type.…”

“…5,6,7,16,17,18,19,20, Advantages over intramedullary fixation are improved rotational stability, ability to incorporate an intercalary graft and no fear of implant migration. 21 Few authors did not find the need of bone grafts from the iliac crest and suggested plating alone, 22,23 especially in hypertrophic types of nonunions 7,24 and well-vascularised bone beds after local preparation. 7 Bone grafts will hasten bone healing when nonunion clavicle is treated with plating and bone graft.…”

“…21 Few authors did not find the need of bone grafts from the iliac crest and suggested plating alone, 22,23 especially in hypertrophic types of nonunions 7,24 and well-vascularised bone beds after local preparation. 7 Bone grafts will hasten bone healing when nonunion clavicle is treated with plating and bone graft. 7 In the case of larger bone defects with clavicle shortening, a tricortical bone was harvested from the iliac crest, whereas cancellous bone was used in smaller defects.…”

“…7 Bone grafts will hasten bone healing when nonunion clavicle is treated with plating and bone graft. 7 In the case of larger bone defects with clavicle shortening, a tricortical bone was harvested from the iliac crest, whereas cancellous bone was used in smaller defects. 7 Bone graft can be harvested either from the fracture site or iliac crest.…”

The challenge of nonunion after osteosynthesis of the clavicle: is it a biomechanical or infection problem?

“…Finally, the construct must be completely coated with the reinsertion of the muscles. Schnetzke et al (35) have shown that an additional clavicle bone graft accelerates healing of non-unions and improves long-term results after 8.9 years of follow-up. Furthermore, the autologous bone grafting was performed to provide the length of the segment.…”