Strategies in Trauma and Limb Reconstruction

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VOLUME 17 , ISSUE 1 ( January-April, 2022 ) > List of Articles

Original Article

Treatment of a Recalcitrant Non-union of the Clavicle

Simran Grewal, Thomas PA Baltes, Esther Wiegerinck

Keywords : Clavicle, Plate fixation, Recalcitrant non-union

Citation Information : Grewal S, Baltes TP, Wiegerinck E. Treatment of a Recalcitrant Non-union of the Clavicle. 2022; 17 (1):1-6.

DOI: 10.5005/jp-journals-10080-1544

License: CC BY-NC-SA 4.0

Published Online: 24-05-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Background: Plate fixation is the treatment of choice for a midshaft clavicle non-union. Those non-unions that require >1 surgical procedure to heal are termed recalcitrant non-union. Regardless of the number of previously failed procedures, our surgical strategy is aimed at achieving an optimal mechanical and biological environment to facilitate healing. Materials and methods: We performed a retrospective analysis of 14 patients with a recalcitrant clavicle non-union treated with open reduction and plate fixation combined with graft augmentation when indicated. Healing rates after index surgery were analysed. All patients were observed for at least 12 months. Results: All patients healed at a mean time of 193.2 days (range 90–390). Five of the 14 patients had at least one positive surprise culture, for which they received antibiotic treatment. At the latest follow-up, no patient reported pain or discomfort. Mean disability of the arm, shoulder and hand (DASH) score was 16.3 points (range 0–40), indicating only mild residual impairment. A possible link was found between the time between injury and definitive surgery and the time to healing [Pearson correlation 0.527, sig. (two-tailed) 0.000]. Conclusion: This study shows 100% bone healing and good functional outcomes after surgical revision for a recalcitrant clavicle non-union.

  1. Lee DH. CORR Insights®: No difference in risk of implant removal between orthogonal mini-fragment and single small-fragment plating of midshaft clavicle fractures in a military population: a preliminary study. Clin Orthop Relat Res 2020;478(4):750–751. DOI: 10.1097/CORR.0000000000000877.
  2. Vannabouathong C, Chiu J, Patel R, et al. An evaluation of treatment options for medial, midshaft, and distal clavicle fractures: a systematic review and meta-analysis. JSES Int 2020;4(2):256–271. DOI: 10.1016/j.jseint.2020.01.010.
  3. Rollo G, Vicenti G, Rotini R, et al. Clavicle aseptic nonunion: is there a place for cortical allogenic strut graft? Injury 2017;48(Suppl 3): S60–S65. DOI: 10.1016/S0020-1383(17)30660-5.
  4. Chen W, Tang K, Tao X, et al. Clavicular non-union treated with fixation using locking compression plate without bone graft. J Orthop Surg Res 2018;13(1):317. DOI: 10.1186/s13018-018-1015-7.
  5. Wiss DA, Garlich JM. Healing the index humeral shaft nonunion: risk factors for development of a recalcitrant nonunion in 125 patients. J Bone Joint Surg 2020;102(5):375–380. DOI: 10.2106/JBJS.19.01115.
  6. Stufkens SA, Kloen P. Treatment of midshaft clavicular delayed and non-unions with anteroinferior locking compression plating. Arch Orthop Trauma Surg 2010;130(2):159–164. DOI: 10.1007/s00402-009-0864-2.
  7. Prasarn ML, Meyers KN, Wilkin G, et al. Dual mini-fragment plating for midshaft clavicle fractures: a clinical and biomechanical investigation. Arch Orthop Trauma Surg 2015;135(12):1655–1662. DOI: 10.1007/s00402-015-2329-0.
  8. Enneking TJ, Hartlief MT, Fontijne WP. Rushpin fixation for midshaft clavicular nonunions: good results in 13/14 cases. Acta Orthop Scand 1999;70(5):514–516. DOI: 10.3109/17453679909000991.
  9. Martetschlager F, Gaskill TR, Millett PJ. Management of clavicle nonunion and malunion. J Shoulder Elbow Surg 2013;22(6):862–868. DOI: 10.1016/j.jse.2013.01.022.
  10. Wessel RN, Schaap GR. Outcome of total claviculectomy in six cases. J Shoulder Elbow Surg 2007;16(3):312–315. DOI: 10.1016/j.jse.2006.07.007.
  11. Wijdicks F-J, Houwert M, Dijkgraaf M, et al. Complications after plate fixation and elastic stable intramedullary nailing of dislocated midshaft clavicle fractures: a retrospective comparison. Int Orthop 2012;36(10):2139–2145. DOI: 10.1007/s00264-012-1615-5.
  12. Lenza M, Buchbinder R, Johnston RV, et al. Surgical versus conservative interventions for treating fractures of the middle third of the clavicle. Cochrane Database Syst Rev 2013;(6):Cd009363. DOI: 10.1002/14651858.CD009363.pub2.
  13. Kloen P, Sorkin AT, Rubel IF, et al. Anteroinferior plating of midshaft clavicular nonunions. Journal of orthopaedic trauma. 2002;16(6): 425–430. DOI: 10.1097/00005131-200207000-00011.
  14. Galdi B, Yoon RS, Choung EW, et al. Anteroinferior 2.7-mm versus 3.5-mm plating for AO/OTA type B clavicle fractures: a comparative cohort clinical outcomes study. J Orthop Trauma 2013;27(3):121–125. DOI: 10.1097/BOT.0b013e3182693f32.
  15. Jones CB, Sietsema DL, Ringler JR, et al. Results of anterior-inferior 2.7-mm dynamic compression plate fixation of midshaft clavicular fractures. J Orthop Trauma 2013;27(3):126–129. DOI: 10.1097/BOT.0b013e318254883a.
  16. Vancleef S, Herteleer M, Carette Y, et al. Why off-the-shelf clavicle plates rarely fit: anatomic analysis of the clavicle through statistical shape modeling. J Shoulder Elbow Surg 2019;28(4):631–638. DOI: 10.1016/j.jse.2018.09.018.
  17. Kalbermatten DF, Haug M, Schaefer DJ, et al. Computer aided designed neo-clavicle out of osteotomized free fibula: case report. Br J Plast Surg 2004;57(7):668–672. DOI: 10.1016/j.bjps.2004.05.013.
  18. Stucken C, Olszewski DC, Creevy WR, et al. Preoperative diagnosis of infection in patients with nonunions. J Bone Joint Surg Am 2013;95(15):1409–1412. DOI: 10.2106/JBJS.L.01034.
  19. Falzarano G, Piscopo A, Grubor P, et al. Use of common inflammatory markers in the long-term screening of total hip arthroprosthesis infections: our experience. Adv Orthop 2017;2017:9679470. DOI: 10.1155/2017/9679470.
  20. Wu CC. Single-stage surgical treatment of infected nonunion of the distal tibia. J Orthop Trauma 2011;25(3):156–161. DOI: 10.1097/BOT.0b013e3181eaaa35.
  21. Amorosa LF, Buirs LD, Bexkens R, et al. A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions: a review of outcomes. J Orthop Trauma 2013;27(10):582–586. DOI: 10.1097/BOT.0b013e31828b76f2.
  22. Kelly JD, 2nd, Hobgood ER. Positive culture rate in revision shoulder arthroplasty. Clin Orthop Relat Res 2009;467(9):2343–2348. DOI: 10.1007/s11999-009-0875-x.
  23. Topolski MS, Chin PY, Sperling JW, et al. Revision shoulder arthroplasty with positive intraoperative cultures: the value of preoperative studies and intraoperative histology. J Shoulder Elbow Surg 2006;15(4):402–406. DOI: 10.1016/j.jse.2005.10.001.
  24. Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am 1996;78(4):512–523. DOI: 10.2106/00004623-199604000-00005.
  25. Both A, Klatte TO, Lübke A, et al. Growth of Cutibacterium acnes is common on osteosynthesis material of the shoulder in patients without signs of infection. Acta Orthop 2018;89(5):580–584. DOI: 10.1080/17453674.2018.1489095.
  26. Ring D, Barrick WT, Jupiter JB. Recalcitrant nonunion. Clin Orthop Relat Res 1997;(340):181–189. DOI: 10.1097/00003086-199707000-00023.
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