Unicortical and bicortical plating in the fixation of comminuted fractures of the clavicle: a biomechanical study.

BACKGROUND: Intraoperative neurovascular complications with clavicle fracture fixation are often due to far cortex penetration by drills and screws, but could be avoided using a unicortical construct. The objective of this study was to compare the bending and torsional strength of a unicortical locking screw plate construct and a hybrid (with central locked and outer non-locked long oblique screws) unicortical plate construct for clavicle fracture fixation with that of a conventional bicortical locking screw construct of plate fixation. METHODS: Twenty-four human clavicle specimens were harvested and fractured in a comminuted mid-shaft butterfly configuration. Clavicles were randomly allocated to three surgical fixation groups: unicortical locking screw, bicortical locking screw and hybrid unicortical screw fixation. Clavicles were tested in torsion and cantilever bending. Construct bending and torsional stiffness were measured, as well as ultimate strength in bending. RESULTS: There were no significant differences in bending stiffness or ultimate bending moment between all three plating techniques. The unicortical locked construct had similar torsional stiffness compared with the bicortical locked construct; however, the hybrid technique was found to have significantly lower torsional stiffness to that of the bicortical locking screw construct (mean difference: 87.5 Nmm/degree, P = 0.028). CONCLUSIONS: Unicortical locked screw plate fixation and hybrid unicortical plating fixation with centrally locked screws and outer long, oblique screws may alleviate far cortex penetration, protecting nearby anatomical structures, and may ease implant removal and conversion to bicortical fixation for revision surgery; however, use of long oblique screws may increase the risk of early loosening under torsion.

A hybrid approach to mid-shaft clavicle fixation.

BACKGROUND: The purpose of this study was to demonstrate the strength characteristics of a hybrid uni-cortical construct for clavicle fixation. The technique reported aims to combine benefits of uni-cortical fixation with stability comparable to traditional bi-cortical fixation. The approach utilises long, oblique uni-cortical screws at the distal ends of the plate acting as surrogate bi-cortical screws. Locked uni-cortical screws positioned centrally provide bending and torsion strength to the construct. This alternative hybrid uni-cortical technique does not require far cortex screw or drill penetration required in bi-cortical fixation techniques, thus avoiding potentially catastrophic vascular and or neurologic injury. The purpose of this study was to compare the mechanical behaviour of the hybrid uni-cortical construct to standard bi-cortical fixations under both torsion and bending loads. METHOD: Thirty osteotomized human cadaveric clavicles were randomly allocated to three surgical fixation techniques: bi-cortical locked screw fixation, bi-cortical non-locked screw fixation and hybrid uni-cortical screw fixation. Each clavicle construct was tested non-destructively under torsional loading, and then under cantilever bending to failure. Construct bending and torsional stiffness, as well as ultimate failure strength, were measured. RESULTS: There were no significant differences between uni-cortical or bi-cortical fixation constructs in either bending stiffness or ultimate bending moment (p>0.05); however, there was a trend towards greater bending stiffness in the hybrid construct. The uni-cortical hybrid fixation technique displayed a significantly lower mean torsional stiffness value when compared with the bi-cortical locked screw fixation (mean difference: 134.4 Nmm/degrees, 95% confidence interval [32.3, 236.4], p=0.007). CONCLUSION: A hybrid uni-cortical approach to clavicle plate fixation that may improve screw purchase and reduce risk of intra-operative vascular damage demonstrates comparable bending strength to current bi-cortical approaches.