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

Abstract

SummaryIntroduction. The nonunion rate has been reported between 0.1% and 15%. There are also several predisposing factors for the onset of complications: general factors connected with the patient and specific factors related to the fracture site. The purpose of our study is to review the etiology of nonunion of the clavicle in its atrophic form and investigate the outcomes of the revision treatment in a single step. Materials and methods. Retrospective study on 71 patients suffering from nonunions due to the following treatments: conservative in 13 patients; plate fixation in 12; closed reduction and fixation with K-wire in 24; open reduction and fixation with K-wire. All patients were operated on in beach chair position and classic approach to the clavicle by incising the previous surgical scar. The clinical and radiographic criteria for evaluating the outcomes were: the Short Form (12) Health Survey (SF-12), the Constant Shoulder Score (CSS) and the Disability Disabilities of the Arm, Shoulder and Score (DASH) and radiographic Union Score (RUS) for bone healing. The evaluation endpoint was set at 12 months. Results. Blood and culture tests showed 22 infected nonunions and 49 atrophic or oligoatrophic. In only 10 cases, before surgery, the inflammatory markers were positive. The isolated microorganisms were resistant to common antibiotics. In 70 out of 71 cases, plates and screws on the upper side and fibula allogenic splints at the bottom, associated with cancellous bone grafts taken from the patients' iliac crests, were implanted. In one case, however, it was decided to implant the plate on the front edge of the clavicle and the fibula allogeneic splint on the posterior margin, also associated with a cancellous bone graft taken from the patient's iliac crest. The radiographic bone healing was observed in 107.8 (range 82-160) days for the aseptic nonunions, while in 118.4 (range 82-203) days for the septic ones. The non-healing case was a serious failure that led to asubtotal excision of the clavicle. Conclusions. The importance of classification and study of nonunions are essential to achieve positive outcomes. The guiding principle of our work is that aseptic nonunions heal in the operating room, while infected nonunions can be challenged and defeated on the operating table. Restoring the correct length of the clavicle interconnection between the sternum and the shoulder cingulum is indispensable to avoid functional deficits of the upper limb. The fibula splint and the tricorticale bone graft have both mechanical and strong biological values to quickly heal the nonunion.The return to pre-injury quality of life has to be our main goal.

Bilaterally Threaded, Minimal Invasive, Elastic Locking Intramedullary Nailing (ELIN) for the Treatment of Clavicle Fractures

“…The purpose of Rollo's study was to review the etiology of nonunion of the clavicle in its atrophic form and investigate the outcomes of the revision treatment in a single step. Rollo also reported that the fibula splint, tricortical bone graft, autologous bone graft and iliac crest bone graft all have mechanical and strong biological values to quickly heal the nonunion. On the other hand all patients treated with ELIN had smooth healing with less complications and more satisfactory results with no revision required for any patient.…”

Grafting and fixation after aseptic non-union of the humeral shaft: A case series

“…Autologous strut grafting with bone chip augmentation has shown to be a reliable option, with sufficient restoration of length and good functional results, yet has a higher patient morbidity from the donor site. 5,7,8,25 The strut allograft provides more stability than one bridging plate only, and even though it is avascular, it could act as a biological scaffold for bone ingrowth on the anteromedial side which is not possible using a double-plating technique.…”

“…The outcomes are often unsatisfactory for the patients, as they are associated with long-term morbidity. 7,8 The purpose of our study is to evaluate the outcomes of plateand-bone strut allograft with bone substitute augmentation in the management of aseptic, atrofic non-unions of the humeral shaft.…”

Lösungsmöglichkeiten bei fehlgeschlagenen Osteosynthesen an Schulter und Schultergürtel

“…Neben der stabilen Plattenosteosynthese ist eine interfragmentäre Kompression an den Kontaktflächen vorteilhaft, weshalb wir trapezartig geformte Knochenblöcke bevorzugen. Die ursprüngliche Länge und Form des Schlüsselbeines muss möglichst wiederhergestellt werden [19]. Daher ist eine genaue präoperative Planung unumgänglich, wobei meist die gesunde Gegenseite als Template herangezogen wird.…”