Elastic Stable Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures-A Randomized, Controlled, Clinical Trial

Smekal, Vinzenz; Irenberger, Alexander; Struve, Peter; Wambacher, Markus; Krappinger, Dietmar; Kralinger, Franz

doi:10.1097/bot.0b013e318190cf88

Cited by 230 publications

(198 citation statements)

References 41 publications

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“…The results of the ASES and DASH scores are comparable to those reported in the literature for intramedullary nails [7,24] and plating [1,22], representing a normal shoulder function. The hospital stay for isolated clavicular fractures was 2.4 days (range, 1-5 days).…”

Section: Discussionsupporting

confidence: 79%

“…Followup (months)* 19 ± 4.1 (15-28) 16 ± 3.4 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27) * Values are expressed as mean ± SD, with range in parentheses; surgery late due to refracture (56 days), delayed union (66 days), and pain after prior nonoperative treatment (26 days); TEN = titanium elastic nail; OTA = Orthopaedic Trauma Association.…”

Section: Indicationsmentioning

confidence: 99%

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Can Complications of Titanium Elastic Nailing With End Cap for Clavicular Fractures Be Reduced?

Frigg

Rillmann²,

Ryf³

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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Background We found treatment of clavicular midshaft fractures using titanium elastic nails (TENs) in combination with postoperative free ROM was associated with a complication rate of 78%. The use of end caps reduced the rate to 60%, which we still considered unacceptably high. Thus, we explored an alternative approach. Questions/purposes We investigated whether (1) the complication rate could be reduced by cautious lateral advancement of the TENs, intraoperative oblique radiographs to rule out lateral perforation, and limited ROM postoperatively; (2) fluoroscopy time could be reduced; and (3) shoulder function would be reasonable. Patients and Methods From March 2006 to December 2009, we treated 44 patients with midshaft clavicular fractures with TENs and end caps. In the first group (n = 15), the TEN was advanced laterally using an oscillating drill. The patients were permitted free ROM. In the second group (n = 29), the TEN was advanced by hand, conversion to open reduction followed two failed closed attempts and lateral perforation was checked with an intraoperative oblique radiograph. Furthermore, anteversion and abduction of the shoulder were limited to 90°for the first 6 weeks. Minimum followup was 12 months (mean, 16.7 months; range, 12-28 months). Results The total complication rate was reduced from nine of 15 in the first group to five of 29 in the second group. Medial perforations ceased with the use of the end cap. Fluoroscopy time was reduced from a mean of 10 to 4 minutes by converting to open reduction after two failed closed attempts. All but three patients exhibited full shoulder ROM at three months and these three had a slight deficit of 10°to 20°in anteversion and/or abduction. At last followup, the mean American Shoulder and Elbow Surgeons score was 92 (range, 88-100) and the Disability of the Arm, Shoulder, and Hand score 1.4 (range, 0-12.5). Conclusions Cautious insertion of the TENs, intraoperative oblique radiographs, and limiting the ROM for 6 weeks postoperatively reduced the complication rate. Using TENs with end caps for midshaft clavicular fractures is minimally invasive while associated with comparable complication rates and function to plate osteosynthesis. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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Section: Discussionsupporting

confidence: 79%

Section: Indicationsmentioning

confidence: 99%

Can Complications of Titanium Elastic Nailing With End Cap for Clavicular Fractures Be Reduced?

Frigg

Rillmann²,

Ryf³

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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“…Collation of literature on clavicle fractures suggests that the expected nonunion rate is 8.6%. This percentage was derived from the reported healing rate in 12 separate publications [59][60][61][62][63][64][65][66][67][68][69][70] spanning the period from 2004 to 2013 and including 3168 patients treated with a range of conservative and operative methods. Both samples are large, and the nonunion rate in our database again differs by less than a percentage point from the literature values.…”

Section: Discussionmentioning

confidence: 99%

Epidemiology of Fracture Nonunion in 18 Human Bones

et al. 2016

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IMPORTANCE Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors.OBJECTIVE To test a hypothesis that fracture characteristics and patient-related risk factors assessable by the clinician at patient presentation can indicate the probability of fracture nonunion.DESIGN, SETTING, AND PARTICIPANTS An inception cohort study in a large payer database of patients with fracture in the United States was conducted using patient-level health claims for medical and drug expenses compiled for approximately 90.1 million patients in calendar year 2011. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology codes; comorbidities as per International Classification of Diseases, Ninth Revision codes; and drug prescriptions as per National Drug Code Directory codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion. Data analysis was performed from January 1, 2011, to December 31, 2012, EXPOSURES Continuous enrollment in the database was required for 12 months after fracture to allow sufficient time to capture a nonunion diagnosis. RESULTSThe final analysis of 309 330 fractures in 18 bones included 178 952 women (57.9%); mean (SD) age was 44.48 (13.68) years. The nonunion rate was 4.9%. Elevated nonunion risk was associated with severe fracture (eg, open fracture, multiple fractures), high body mass index, smoking, and alcoholism. Women experienced more fractures, but men were more prone to nonunion. The nonunion rate also varied with fracture location: scaphoid, tibia plus fibula, and femur were most likely to be nonunion. The ORs for nonunion fractures were significantly increased for risk factors, including number of fractures (OR, 2.65; 95% CI, 2.34-2.99), use of nonsteroidal anti-inflammatory drugs plus opioids (OR, 1.84; 95% CI, 1.73-1.95), operative treatment (OR, 1.78; 95% CI, 1.69-1.86), open fracture (OR, 1.66; 95% CI, 1.55-1.77), anticoagulant use (OR, 1.58; 95% CI, 1.51-1.66), osteoarthritis with rheumatoid arthritis (OR, 1.58; 95% CI, 1.38-1.82), anticonvulsant use with benzodiazepines (OR, 1.49; 95% CI, 1.36-1.62), opioid use (OR, 1.43; 95% CI, 1.34-1.52), diabetes (OR, 1.40; 95% CI, 1.21-1.61), high-energy injury (OR, 1.38; 95% CI, 1.27-1.49), anticonvulsant use (OR, 1.37; 95% CI, 1.31-1.43), osteoporosis (OR, 1.24; 95% CI, 1.14-1.34), male gender (OR, 1.21; 95% CI, 1.16-1.25), insulin use (OR, 1.21; 95% CI, 1.10-1.31), smoking (OR, 1.20; 95% CI, 1.14-1.26), benzodiazepine use (OR, 1.20; 95% CI, 1.10-1.31), obesity (OR, 1.19; 95% CI, 1.12-1.25), antibiotic use (OR, 1.17; 95% CI, 1.13-1.21), osteoporosis medication use (OR, 1.17; 95% CI, 1.08-1.26), vitamin D deficiency (OR, 1.14; 95% CI, 1.05-1.22), diuretic use (OR, 1.13; 95% CI, 1.07-1.18), and renal insufficiency (OR, 1.11; 95% CI, 1.04-1.17) (multivariate P < .001 for all).C...

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“…Our results can be compared with other recent studies (Table 1) [3,4,6,8,10,12,16,19,23,24]. Our investigation is the only one that compared nonoperative versus plating treatment using both DASH and CSS scores.…”

Section: Discussionmentioning

confidence: 61%

“…Third, DASH and CSS scores do not consider individual patient differences resulting from age, general health, or personal problems. Even so, DASH and CSS have been used widely as standard measures of function [3,4,6,8,10,12,16,19,23,24]. Fourth, there was substantial preoperative delay in some cases, so some fractures may have partially healed by 28 days.…”

Section: Discussionmentioning

confidence: 99%

Function Plateaus by One Year in Patients With Surgically Treated Displaced Midshaft Clavicle Fractures

Schemitsch

Veillette

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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Background Based on short-term (1 year or less) followup, primary fixation of displaced midshaft clavicle fractures reportedly results in better function compared with that reported for nonoperative methods. Whether better function persists beyond 1 year is unclear. Questions/purposes For displaced midshaft clavicle fractures, do the better mean Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley Shoulder (CSS) scores for operative versus nonoperative treatment at 1 year change between 1-and 2-year followup? Patients and Methods We previously reported 132 patients in a randomized prospective trial at 1 year, and here we report a further followup of 95 of the 132 patients (72%) at 2 years after injury. We evaluated all patients with the DASH and CSS scores. Results The mean DASH and CSS scores were similar at 2 years compared with 1 year postinjury for both the nonoperated and operated patients. The mean scores for the operated patients remained higher than those in the nonoperative group (DASH operative 4

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Elastic Stable Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures-A Randomized, Controlled, Clinical Trial

Abstract: ESIN of displaced midshaft clavicular fractures resulted in a lower rate of nonunion and delayed union, a faster return to daily activities, and a better functional outcome. Clavicular shortening was significantly lower, and overall satisfaction was higher in the operative group.

Cited by 230 publications

References 41 publications

Can Complications of Titanium Elastic Nailing With End Cap for Clavicular Fractures Be Reduced?

Can Complications of Titanium Elastic Nailing With End Cap for Clavicular Fractures Be Reduced?

Epidemiology of Fracture Nonunion in 18 Human Bones

Function Plateaus by One Year in Patients With Surgically Treated Displaced Midshaft Clavicle Fractures

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