Stand-alone coracoclavicular suture repair achieves very good results in unstable distal clavicle fractures at a minimum follow-up of 1 year

Abstract

Background: The treatment of unstable (Neer type IIB and V) extra-articular distal clavicle fractures remains challenging, especially when encountering a small lateral fragment which does not allow for sufficient screw purchase. It was the purpose of this study to present the clinical and radiologic outcome of a consecutive series of patients treated by a stand-alone coracoclavicular stabilization using a so-called cow-hitch technique with a suture anchor. Methods: Nineteen patients were treated with a specific surgical technique for distal clavicle fractures (11 left, 8 right) with either rupture or bony avulsion of the coracoclavicular ligaments. Fourteen patients were examined in our outpatient clinic for the purpose of this study after a mean follow-up of 5 years (1-12.2 years). The examination included scoring according to Constant Murley score (CMS), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the Subjective Shoulder Value (SSV), and follow-up radiographs. Two additional patients were amenable to a telephone interview. Results: All patients reported very good subjective results, with a mean SSV of 92% and a mean ASES score of 96%. The CMS resulted in average absolute values of 92 points. Fractures consolidated in 95% of cases. One patient developed an asymptomatic pseudarthrosis. The coracoclavicular distance was restored from 21 mm preoperatively to 11 mm at the final follow-up and finally showed an average side-to-side difference of þ1.8 mm. Sports activities were fully resumed after an average of 4.7 months. Conclusion:The coracoclavicular stand-alone cow-hitch suture repair for unstable distal clavicle fractures is a minimally invasive fixation technique without prominent hardware that allows for an anatomic reduction and stable fixation with a low complication and high bony union rate. Both radiographic and clinical long-term results are very satisfactory.

Fixation of distal clavicle fractures with coracoclavicular instability: a comparative biomechanical study in human cadavers

“…Complementary to a clinical case series, 13 the present study now also provides biomechanical evidence that the use of the occasionally irritating clavicular button is dispensable when using the cow-hitch suture technique and, thus, the number of secondary surgeries can be reduced in patients with distal clavicle fractures.…”

“…Compared with the original description, 14 the cow-hitch technique was later modified by using a suture button to combat the risk of anchor pullout through a larger and cortical rather than cancellous implant-bone interface and avoid the risk of suture breakage at the anchor eyelet. 6 In addition, fixation in this manner is assumed to be more independent of bone quality.…”

“… 29 The recently introduced cow-hitch fixation technique of distal clavicle fractures offers several clinical advantages, such as the absence of prominent hardware, suture slippage, and a sawing effect in combination with possible interfragmentary compression and distribution of compressive forces due to a larger contact area. 13 , 24 The double-strand design of this knot has been shown to be up to three times stronger and significantly stiffer, holds the initially applied tension about a factor of 10 better, and yet has the smallest knot volume compared with conventional knots. 18 In clinical practice, the cow-hitch knots are tied anteroinferiorly and the free suture ends are later used to close the deltotrapezoid interval with immersed knots.…”

“…Owing to the hereby achieved soft-tissue coverage and the deltotrapezoid fascia countersunk suture knots below, local irritations can be avoided, as recently shown in a clinical case series. 13 The purpose of this study is to investigate the biomechanical properties of two CC stabilization techniques. Overall fixation strength and cyclic loading properties of a cow-hitch suture repair with distal only button fixation were compared with those of a well-studied suture tape double-button fixation (Arthrex Dog Bone) in a human cadaver model.…”

Accelerated rehabilitation in treating neer type V distal clavicle fractures using anatomical locking plates with coracoclavicular ligament augmentation

“…Some scholars have suggested that reconstructing ligament stability can shorten the CC distance and enhance the fixation stability of clavicle fractures [ 9 , [13] , [14] , [15] ]. However, others believe that there is no significant difference in the final fracture healing effect and shoulder function between treatments using plate fixation alone and plate fixation with additional CC ligament augmentation [ 10 , 11 , 16 , 17 ]. Almost all reports have evaluated Neer type V and II fractures together as unstable distal clavicle fractures or only Neer type II fractures.…”