Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle.

OBJECTIVE: Results of surgical treatment for clavicle injuries using standard approaches have shown relatively high complication rates including loss of fixation, persistent nonunion, implant related problems, and the need for subsequent surgeries are common. The purpose of this study is to evaluate the clinical results of patients treated for clavicle fractures and painful clavicular nonunions with anterior-inferior plating using a 3.5 mm plate. DESIGN: Consecutive clinical series. SETTING: 3 tertiary care academic trauma centers (Level 1 and 2). PATIENTS: Eighty consecutive patients with a middle-third fracture or painful nonunion of the clavicle. INTERVENTION: Open reduction and internal fixation using an anterior-inferior plating technique with a precontoured 3.5 mm plate and lag screw(s). Nonunions received autologous bone grafts. MAIN OUTCOME MEASUREMENTS: Patients were evaluated using physical and radiographic examination, the American Shoulder and Elbow Surgeons Shoulder Assessment (ASES), and the Short Form-36 (SF-36) outcomes questionnaire. RESULTS: Fifty-eight patients had sufficient records and follow-up of at least 24 months (mean 49 months). Clinical and radiographic union was present at a mean of 9.5 weeks for patients treated for acute fracture and 10.5 weeks those treated for nonunion. Complications included 1 failure of fixation, 1 nonunion, and 3 infections. Two patients underwent implant removal for bothersome hardware. Shoulder motion was good or excellent in all patients except those with neurologic injury. Functional results (ASES and SF-36) were good or excellent for the vast majority of patients, except those with neurologic injury. CONCLUSIONS: Anterior-inferior plating of acute middle-third fractures of the clavicle and clavicular nonunions using a plate and lag screws typically results in early healing, few complications and an excellent return of function. Advantages of this technique include stable bony fixation with instrumentation directed away from potentially dangerous infraclavicular structures and a minimal incidence of implant prominence problems.

Trochanteric nail insertion for the treatment of femoral shaft fractures.

OBJECTIVES: This study was designed to evaluate whether the use of a new femoral nail, specifically designed to be inserted through the greater trochanter, could eliminate the complications previously seen with insertion of straight nails through this entry portal for the treatment of femoral shaft fractures. DESIGN: Prospective, clinical trial. SETTING: Three level I trauma centers. PATIENTS: Sixty-one consecutive patients with femoral shaft fractures (50 closed and 11 open fractures) treated with antegrade nailing with insertion through the greater trochanter. INTERVENTION: All patients were treated in the supine position with a TAN nail (Trigen System, Smith & Nephew, Memphis, TN) inserted through the greater trochanter. MAIN OUTCOME MEASURE: Union, alignment, complications, and hip function. RESULTS: Forty-six of 57 (81%) surviving patients were available for follow-up at a minimum of 12 (range, 12-25) months. Union occurred in all but 1 fracture after the index procedure. No patient sustained iatrogenic fracture comminution, and there were no angular malunions. Pain was reported as slight in 6 patients and moderate in 2. Visual and videotaped gate analysis, performed on 24 patients, revealed symmetrical walking in 21. CONCLUSIONS: This study demonstrates that antegrade nailing of femoral shaft fractures with a specially designed nail inserted through a trochanteric starting point provides predictably high union rates and low rates of complications. Ease of entry and utility in patients with a large body habitus are advantages over conventional piriformis fossa entry techniques. Nailing through the greater trochanter with the patient supine is presently our treatment of choice for patients with femoral shaft fractures.