Outcomes and complications after dual plate vs. single plate fixation of displaced mid-shaft clavicle fractures: A systematic review and meta-analysis

Abstract

Introduction: Open reduction and internal fixation (ORIF) of displaced midshaft clavicle fractures is associated with higher union rates and earlier functional recovery. However, ORIF with plate fixation is associated with complications including implant irritation and implant failure. Dual plate fixation provides fixation in orthogonal planes, and uses a lower profile fixation technique in comparison to precontoured and surgeon-contoured small-fragment locking plates, which may be more prominent. The objective of this study was to conduct a systematic review to summarize outcomes and complications associated with surgical fixation of displaced acute midshaft clavicle fractures with dual plate fixation. Methods: Using a predetermined study protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the databases MEDLINE, EMBASE, and CENTRAL were searched from inception to 2020 to identify studies reporting outcomes in acute midshaft clavicle fractures treated with dual plate fixation. All clinical studies which reported on outcomes of dual plating in patients with acute midshaft clavicle fractures were included. Baseline demographics, plate fixation constructs, fracture union rates, implant removal rates, maintenance of reduction, symptomatic implant rates, wound complications, and functional outcomes were extracted. All extracted data were recorded, and descriptive statistics were summarized. Meta-analysis was performed on fracture union rates and implant removal rates using random-effects modeling using Mantel-Haenszel weighting. Results: Our literature search identified 2226 unique abstracts, of which eight studies met our study inclusion criteria following review. A total of 278 patients made up of 79.8% male with an average age of 36.0 years were included. The overall dual plate implant removal rate was 4.2% with excellent rates of union reported. Moreover, single plate fixation was associated with a 3.9-fold increased implant removal rate compared to dual plate fixation. Conclusion: Results from this systematic review demonstrate that ORIF of displaced midshaft clavicle fractures using a dual plate fixation technique is a viable option to reduce the incidence of implant removal, without negatively impacting the rate of fracture union.

Biomechanical Evaluation of Different Plate Configurations for Midshaft Clavicle Fracture Fixation

“…Additionally, a too-rigid construct might predispose to higher nonunion rates. However, a systematic review and meta-analysis described excellent union rates for dual plating (99.5%) and no significant differences were observed among all surgical fixation types 8 . It seems that dual plating is biomechanically superior for fixation of midshaft clavicle fractures when compared with a single superior plate.…”

“…The 6 different plate configurations (4 per group), all from DePuy Synthes, included superior plating using a single 7-hole (110 mm in length), precontoured, 3.5-mm Superior Clavicle Locking Compression Plate (LCP); anterior plating using a single 7-hole (90 mm in length), 3.5-mm Medial Anterior Clavicle LCP; or 4 different dual-plating constructs (Table I) with superior and anteroinferior plating using a Modular Mini Fragment 5-hole 2.4-mm LCP (44 mm in length) or 2.7-mm LCP (49 mm) and a 12-hole Adaptation 2.4-mm plate (88 mm in length) or 2.7-mm plate (97 mm in length). These 4 different dual-plating constructs were chosen as they were the most commonly used in previous studies 8 and in our current clinical practice. To allow for controlled osteotomy and reproducible fixation, the superior plate (or the anterior plate in the case of a single anterior plate configuration) was applied first before creating the inferior butterfly fragment (Fig.…”

“…It is a lower-profile construct in comparison with the traditionally used (contoured) small-fragment plates and could potentially reduce secondary surgical procedures because of less prominent implants 13 . In a recent systematic review and meta-analysis (278 patients), a 4.2% implant removal rate was reported for the dual-plating technique, and single-plate fixation was associated with a 3.9-fold increased implant removal rate (p = 0.003) 8 . This difference in implant removal rate is less pronounced with a single plate placed anteroinferiorly compared with superior plating 18 .…”

“…Most of the debate surrounds secondary operative procedures, as the number of patients who require a second operation (8.0% to 20.8%) is considerable 6,8 . The most common indication for a secondary surgical procedure is implant irritation 8 .…”

“…Nonetheless, the recommended indications for surgical treatment are still conflicting. Most of the debate surrounds secondary operative procedures, as the number of patients who require a second operation (8.0% to 20.8%) is considerable 6,8 . The most common indication for a secondary surgical procedure is implant irritation 8 .Although various fixation methods of midshaft clavicle fractures have been described, plate fixation remains the most established method 9 .…”