Outcomes following fixation of distal clavicle fractures utilizing arthroscopically assisted coracoclavicular ligament stabilization with a suspensory endobutton and cerclage tape.

Background: Distal one-third clavicle fractures are frequently unstable and often require surgical fixation due to high rates of nonunion. Many common methods of fixation have high rates of union but are associated with hardware discomfort and need for secondary surgery. The purpose of this study was to evaluate the outcomes of a fixation technique involving arthroscopically assisted open reduction internal fixation of unstable distal clavicle fractures via a coracoclavicular (CC) suspensory endobutton and cerclage tape. Methods: This was a retrospective case series evaluating patients who underwent fixation of unstable distal clavicle fractures via arthroscopically assisted CC stabilization by a single fellowship-trained shoulder and elbow surgeon between 2020 and 2022. Demographic and injury-related data were collected via chart review. Preoperative and postoperative radiographs were reviewed to evaluate for signs of radiographic union. Primary outcome measures included fracture union, complications, and need for additional procedures. Patients were also contacted via telephone to obtain American Shoulder and Elbow Surgeons scores. Results: Six patients were eligible for inclusion in this study with a mean age of 52.8 ± 14.0 and a mean follow-up of 2.0 years (range 1.6-2.7 years). Mean American Shoulder and Elbow Surgeons scores were 86.2 ± 21.8 (range 52-100). There were no postoperative complications, signs of symptomatic hardware, or need for secondary surgery at the final follow-up among this cohort of patients. All patients had achieved and maintained full radiographic union at a mean radiographic follow-up of 5.5 months (range 2.0-12.9 months). Conclusion: Arthroscopically assisted CC stabilization of distal clavicle fractures demonstrated high union rates while limiting complications or need for secondary hardware removal. Further analysis on a larger scale is recommended to determine long-term outcomes and direct comparison to other surgical techniques.

Hook plate fixation of Neer type II distal clavicle fractures results in satisfactory patient-reported outcomes but complications and revisions are high.

BACKGROUND: Surgical treatment of distal clavicle fractures Neer type II is challenging. A gold standard has not yet been established, thus various surgical procedures have been described. The purpose of this study is to report the radiological and clinical outcomes using hook plate fixation in Neer type II distal clavicle fractures. METHODS: We retrospectively reviewed data of 53 patients who underwent hook plate fixation between December 2009 and December 2019 with ≥ 2 years of follow-up. Patients with preexisting pathologies or concomitant injuries of the ipsilateral shoulder were excluded. Pre- and postoperative coracoclavicular distance (CCD), bony union and patient-reported outcomes were collected, including the Constant Score (CS) and Subjective Shoulder Value (SSV). Complications and revisions were recorded. RESULTS: At a mean final follow-up of 6.2 years, mean SSV was 91.0% (range, 20-100) and mean CS was 80.9 points (range, 25-99). The mean preoperative CCD was 19.0 mm (range, 5.7-31.8), the mean postoperative CCD was 8.2 mm (range, 4.4-12.2) and the mean CCD following hardware removal was 9.7 mm (range, 4.7-18.8). The loss of reduction following hardware removal was statistically significant (P = 0.007). Eleven (20.8%) patients had complications, with 5 cases of deep or superficial infection (9.4%), four non-unions (7.5%), one periosteosynthetic fracture, one postoperative seroma, one implant failure and one symptomatic acromioclavicular joint arthritis (all 1.9%). A total of 10 patients (18.9%) underwent revision surgery at a mean of 113 (range, 7-631) days. CONCLUSION: Medium-term patient-reported outcomes for hook plate fixation of Neer type II distal clavicle fractures are satisfactory; however, one in five patients suffers a complication with the majority of them requiring revision surgery.

Triple Endobutton technique for the treatment of Neer type II lateral clavicle fractures: 2-year findings.

BACKGROUND: Although various kinds of operative procedures have been reported in the literature, there is still no undisputed gold standard technique for the treatment of Neer type II lateral clavicle fractures. This trauma is classified as a bone fracture, but it is primarily a ligamentous problem due to the instability it generates. This study analyzed the clinical and radiological results of treatment for Neer type II lateral clavicle fractures using the triple Endobutton (Smith & Nephew) technique in 20 patients with at least 2 years of follow-up. METHODS: This study enrolled 20 patients with Neer type II distal clavicle fractures who underwent the triple Endobutton technique using 3 Endobuttons (1 with a closed loop and 2 without) and 3 No. 5 Ethibond sutures (Ethicon Inc.) from October 2017 to May 2020. Patients were assessed with clinical and radiological follow-up at 3, 6, 12, and 24 months postoperatively. Clinical assessments consisted of the visual analog scale and the Constant score. Radiological evaluation was achieved by measuring the coracoclavicular distance. RESULTS: The mean follow-up was 35 ± 9 months (range, 24-55 months). The visual analog scale and Constant scores revealed significant improvements from 6 ± 1 (range, 4-8) and 42 ± 4 (range, 35-48) scores preoperatively to 1 ± 1 (range, 0-1) and 94 ± 2 (range, 90-98) scores at the final evaluation, respectively (P < .001). The coracoclavicular distance of the injured side was an average of 9 ± 1 mm (range, 7-12 mm) at the final follow-up radiograph which was not significantly different from that of the contralateral side (P = .75). CONCLUSIONS: In this study, the triple Endobutton technique was a safe, reliable, and novel surgical technique that yielded good to excellent short-term clinical and radiological outcomes for the treatment of Neer type II distal clavicle fractures.

Coraco-clavicular endobutton and fiber tape fixation for Neer's type II unstable lateral clavicular fracture: a case series with literature review.

Neer's type II lateral end clavicle fracture is inherently unstable due to coraco-clavicular ligament disruption. Timely surgery can avoid complications of conservative management. Our study is based on open reduction and fixation with double endobutton and fibre tape in 12 patients. Radiological and functional outcome were assessed using Quick DASH score and SPADI score at regular interval. All the fractures achieved both clinical and radiological union. No intra-operative or post-operative complication was noted. Functional out come and range of motion at 1-year follow-up was quite satisfactory. Open reduction and fixation with double endobutton and fibre tape for lateral end clavicle fracture is a quite rewarding surgery with less steep learning curve, economical and enough stable fixations leading to union and good functional outcome without need of re-surgery for implant removal.

Clinical outcomes of a combined osteoligamentous reconstruction technique of Neer Type IIB distal clavicle fractures.

PURPOSE: To evaluate outcomes for a combined osteoligamentous reconstruction technique for Neer Type IIB clavicle fractures. METHODS: Patients with Neer Type IIB clavicle fractures treated with combined clavicular locking plate and coracoclavicular ligament suture reconstruction were identified. Demographics, clinical outcomes, and radiographic outcomes were collected. RESULTS: Twenty-four patients with mean 13 months of follow-up were included. Bony union and normal radiographic coracoclavicular relationship were achieved in 23 (96%) patients. The mean UCLA Shoulder score was 33.3. Three (13%) complications occurred. DISCUSSION: The combined osteoligamentous reconstruction approach as described is a successful option for treating Neer Type IIB clavicle fractures.

Locking plate combined with titanium cable for Neer type II distal clavicle fractures.

BACKGROUND: There is controversy about the optimal strategy treatment of unstable distal clavicle fractures. We explored use of a surgical strategy: combination of a distal clavicle locking plate and a titanium cable. The purpose of this retrospective case series study was to evaluate the clinical outcomes of this new strategy in treating Neer type II distal clavicle fractures. METHODS: Twenty-one patients with Neer type II distal clavicle fracture were treated with a distal clavicle locking plate and a titanium cable. All patients were followed for at least one year. We retrospectively collected and reviewed follow-up data. The clinical outcomes were assessed for union rate, functional score, and complication rate. RESULTS: All patients achieved bony union within 6 months. The average follow-up period was 20.6 months (range12-48 months). The mean Constant score at one-year follow-up was 94.6 ± 3.3 (range 84-98), and the mean UCLA (University of California, Los Angeles) score was 33.3 ± 2.6 (range 27-35). Only one complication (wound infection) was observed during follow-up. Two patients received another operation for implant removal due to local irritation. CONCLUSIONS: Use of a distal clavicle locking plate in combination with a titanium cable for treatment of Neer type II fractures results in high union rate, a low complication rate, and good shoulder function. This combined surgical strategy can be considered an effective method for treating unstable distal clavicle fractures.

Clinical Outcome of Neer Type II Lateral End Clavicle Fractures With Coracoclavicular Ligament Disruption Treated With Pre-Contoured Locking Plate and Endobutton.

Introduction Many surgical techniques have been described for the treatment of Neer type II lateral end clavicle fractures like open reduction and internal fixation with hook plate, tension band wiring, coracoclavicular screw fixation, and distal clavicle locking plate. However, most of these operative procedures are associated with high perioperative complications ranging from hardware prominence, hardware failure, screw and plate pull-out, and infection. As the lateral end clavicle fractures has both vertical and horizontal stress forces, any technique counteracting both the forces should result in a better clinical outcome. Therefore, this study was conducted to assess the functional and radiological outcome of type II lateral end clavicle fracture treated using pre-contoured locking plate along with coracoclavicular reconstruction with endobutton and fiberwire. Methods Thirty-two consecutive patients with Neer type II fractures of the lateral end of clavicle were treated surgically using pre-contoured locking plate and coracoclavicular reconstruction with endobutton and fiberwire between May 2014 and December 2016. Clinical outcome was assessed using the University of California Los Angeles (UCLA) shoulder score and Constant Murley score. The coracoclavicular distance was also recorded. These were compared to the unaffected side at one-year follow-up. Results The bony union was achieved in all cases. There were no major complications in any of the patients. All the patients were able to return to their preinjury level of activity. The UCLA score, the Constant Murley score, and coracoclavicular distance did not vary significantly at a one-year interval when compared to the normal shoulder. Conclusion Open reduction and internal fixation of Neer type II lateral end clavicle fractures using pre-contoured locking distal clavicle plate along with coracoclavicular reconstruction with endobutton and No. 2 fiberwire provide an excellent functional and radiological outcome.

Lateral Clavicle Fractures with Coracoclavicular Ligament Disruption (Neer's Type IIB): Review of Literature and a New Technique for All-Suture Fixation.

BACKGROUND: All-suture fixation for the treatment of Neer's Type IIB lateral clavicle fractures by coracoclavicular (CC) ligament reconstruction has become popular in the past decade. Results of modified under-coracoid-around-clavicle (UCAC) technique are reported in this paper. METHODOLOGY AND RESULTS: Nineteen consecutive patients with minimum 6-month followup (FU) were identified. Average FU was 23 months (6-47 m), mean age was 38 years (16-81), and male-to-female ratio was 2:1. The time to surgery varied from 4 days to 12 weeks. Two patients had primary lateral end excision; of the rest, all but one healed fully. Average time to regain full range of motion was 4 weeks; postoperative Oxford Shoulder Score at 6 months was 43. All the patients returned to their previous occupation. One patient showed mild osteolysis on the last X-rays. There were no cases with infections or stiffness. DISCUSSION: CC ligament reconstruction converts the unstable Type IIB fracture into stable Type I; therefore, it is unnecessary to fix the distal fragment separately. Standard plating procedures are technically challenging due to small lateral fragment and frequently require a second operation for implant removal. The cost of commercially available implants vary from ≤750 to ≤1450. This technique is quick, easy to perform, provides good primary stability, and comparable union rates with other techniques at an implant cost of <£120. CONCLUSION: This is a reproducible and efficient technique that provides comparable results with other established procedures at a fraction of the cost of the next cheapest implant. It is recommended for the treatment of displaced Type II clavicle fractures. LEVEL OF EVIDENCE: Level IV.

Treatment of unstable distal clavicle fractures (Neer type II): A comparison of three internal fixation methods.

OBJECTIVE: This study was performed to compare the clinical efficacy of three internal fixation methods for distal clavicle fractures (Neer type II): clavicular hook plate (Group A), anatomical plate (Group B), and arthroscopic Endobutton (Group C). METHODS: From 2001 to 2014, 58 patients with Neer type II distal clavicle fractures were treated at our institution. The clinical results were assessed with the visual analog scale (VAS), Constant score, and Simple Shoulder Test (SST) score. RESULTS: All patients had anatomic reduction and bone healing at the final follow-up. Groups B and C had considerably less intraoperative blood loss than Group A. The incision was significantly shorter in Group C than in Groups A and B. The mean VAS score was significantly higher in the affected than unaffected shoulder. The Constant and SST scores were significantly higher in the unaffected than affected shoulder. The VAS, Constant, and SST scores of the affected shoulders were not significantly different among the three groups. CONCLUSIONS: Arthroscopic Endobutton fixation has long-term clinical results similar to those of other surgical protocols for distal clavicle fractures (Neer type II). We recommend this technique because of less blood loss, shorter incision length, and less shoulder irritation than other methods.

Comparing the coracoclavicular loop technique with a hook plate for the treatment of distal clavicle fractures.

BACKGROUND: Treatment of displaced distal clavicular fractures is still controversial. This study reports the utility of a new coracoclavicular (CC) loop technique for acute displaced distal clavicular fractures and compared its surgical outcomes with those of the hook plate method. METHODS: In this retrospective study, a total of 23 patients with acute displaced distal clavicular fractures were treated with a new CC loop technique at a single institution from 2010 to 2014. Another group comprising 49 patients treated with a hook plate was compared with the CC loop group regarding clinical and radiologic outcomes. RESULTS: Seventy-two patients with at least 1 year of follow-up after both operations were included in this study. The Constant score was significantly greater in the CC loop group (95 vs 87, P = .009) at final follow-up. Moreover, the complication rate was significantly lower in the CC loop group (0% vs 24.5%, P = .007). The University of California, Los Angeles shoulder score and radiologic nonunion rate revealed no significant differences between the 2 groups. CONCLUSIONS: The new CC loop technique had better clinical outcomes and lower complication rates compared with the hook plate technique.

Clinical efficacies of coracoclavicular ligament reconstruction using suture anchor versus hook plate in the treatment of distal clavicle fracture.

INTRODUCTION: Comparison of clinical efficacies between coracoclavicular ligament reconstruction using autologous gracilis tendon with suture anchor and clavicular hook plate for the treatment of acute Neer type II distal clavicle fracture. HYPOTHESIS: Both coracoclavicular reconstruction with autologous gracilis tendon and clavicular hook plate could achieve satisfactory results for treating acute Neer type II distal clavicle fracture. METHODS: Acute Neer type II distal clavicle fracture patients enrolled in this prospective randomized study were divided into the coracoclavicular ligament reconstruction group (using autologous gracilis tendon and suture anchor) and the hook plate group. Clinical outcomes were evaluated by shoulder X-ray, forward flexion, abduction and external rotation angle, Constant-Murley shoulder score and pain Visual Analogue Scale (VAS) at each follow-up for up to 24 months. RESULTS: The current study enrolled a total of 42 acute Neer type II distal clavicle fracture patients attended our hospital from March 2010 to December 2013. All patients had achieved complete healing and followed up for an average of 26 months (range, 24-38 months). At 3-month and 6-month follow-ups, Constant-Murley score in the ligament reconstruction group was significantly higher (93.8±2.6 vs. 88.7±8.7; 95.9±2.7 vs. 93.0±7.0, P<0.05), while VAS score was poorer than those in the hook plate group (1.6±0.8 vs. 2.5±1.9; 1.1±1.0 vs. 1.6±1.7, P<0.05). DISCUSSION: Reconstruction with autologous gracilis tendon improved VAS pain score in early postoperation follow-up; while Constant-Murley score and VAS score were significantly improved in the hook plate group after the implant was removed. These suggested that both coracoclavicular reconstruction with autologous gracilis tendon and clavicular hook plate could achieve satisfactory results. LEVEL OF EVIDENCE: Level II, low-powered prospective randomized trial.

Innovative use of single-incision internal fixation of distal clavicle fractures augmented with coracoclavicular stabilisation.

INTRODUCTION: The management of displaced fractures of the distal clavicle remains controversial, particularly in younger patients where there is no consensus as to which surgical intervention is best. Each surgical method has unique surgical complications and rates of persistent pain and post-traumatic arthritis. We report an innovative surgical technique using a plate fixation augmented with minimally invasive tension slide coracoclavicular fixation using a cortical tenodesis button (8.5 mm). METHODS: A single-surgeon series, comprising of eleven cases, underwent retrospective review. A low-profile pre-contoured stainless steel plate that combines locking and non-locking options was used. Secondary fixation to the coracoid, through the plate, was achieved under fluoroscopic guidance eliminating the need for arthroscopy or exposure of the coracoid. An 8.5-mm cortical button loaded with a single FiberTape is inserted with fluoroscopic navigation, flipped under the coracoid and fixed to the plate. Patients followed a standardised rehabilitation protocol and clinical review assessing time to union, complications and Oxford Shoulder Scores. RESULTS: The mean age of the patients was 40 years, 82% male. The majority were day-case admissions with a mean follow-up of 18 months. Although a single patient requested plate removal due to lateral prominance, there were no revisions for implant failure and no surgical site infections or neurovascular injuries. All patients were reviewed at a minimum of 17 weeks and were progressing to union. Mean Oxford Shoulder Score was 43 (28-48, SD 6.5). CONCLUSION: We consider this technique ideal for treating Neer type II distal clavicle fractures or fractures that have poor bone quality laterally, in which it can be difficult to achieve adequate screw fixation. The technique benefits from smaller tunnel diameter (3.7-mm spade-tip drill) and button length (8.5 mm). The procedure has a short learning curve and is both safe and time efficient. LEVEL OF EVIDENCE: IV.

Closed-Loop Double Endobutton Technique for Repair of Unstable Distal Clavicle Fractures.

BACKGROUND: Displaced fractures of the distal clavicle are inherently unstable and lead to nonunion in a high percentage of cases. The optimal surgical management remains controversial. HYPOTHESIS: Indirect osteosynthesis with a closed-loop double endobutton construct would result in reliable fracture union and obviate the need for additional surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eight patients with an acute unstable Neer type IIB distal clavicle fracture were treated with a closed-loop double endobutton implant. Mean follow-up averaged 3.4 years (range, 1-9 years). Two patients were lost to follow-up. The remaining 6 patients underwent a detailed functional and radiologic evaluation. RESULTS: Definitive fracture healing was achieved in all patients. There were no complications, and no patients required additional surgery related to the index procedure. The mean Constant score was 97 at final follow-up. CONCLUSION: The closed-loop double endobutton technique was reliable and effective in achieving fracture union in all patients with unstable Neer type IIB fractures of the distal clavicle. This technique obviates the need for late hardware removal that is often necessary when direct osteosynthesis is used and avoids potential complications associated with coracoclavicular cerclage constructs that require knot fixation.

Under-coracoid-around-clavicle (UCAC) loop in type II distal clavicle fractures.

In Neer type II (Robinson type 3B) fractures of the distal clavicle the medial fragment is detached from the coracoclavicular ligaments and displaced upwards, whereas the lateral fragment, which is usually small, maintains its position. Several fixation techniques have been suggested to treat this fracture. The aim of this study was to assess the outcome of patients with type II distal clavicle fractures treated with coracoclavicular suture fixation using three loops of Ethibond. This prospective study included 14 patients with Neer type II fractures treated with open reduction and coracoclavicular fixation. Ethibond sutures were passed under the coracoid and around the clavicle (UCAC loop) without making any drill holes in the proximal or distal fragments. There were 11 men and three women with a mean age of 34.57 years (29 to 41). Patients were followed for a mean of 24.64 months (14 to 31) and evaluated radiologically and clinically using the Constant score. Fracture union was obtained in 13 patients at a mean of 18.23 weeks (13 to 23) and the mean Constant score was 96.07 (91 to 100). One patient developed an asymptomatic fibrous nonunion at one year. This study suggests that open reduction and internal fixation of unstable distal clavicle fractures using UCAC loops can provide rigid fixation and lead to bony union. This technique avoids using metal hardware, preserves the acromioclavicular joint and provides adequate stability with excellent results.

Comparison of Results of Tension Band Wire and Hook Plate in the Treatment of Unstable Fractures of the Distal Clavicle

PURPOSE: To compare the clinical and radiological outcomes of two surgical methods with tension band wire and Hook plate for unstable distal clavicle fractures. MATERIALS AND METHODS: Thirty patients with type II distal clavicle fractures were evaluated, who were operated with tension band wire (Group I) and Hook plate (Group II) fixation, from June 2005 to June 2009, and could be followed-up for more than 1 year after operation. The reduction and union were evaluated by the immediate post-operative and final radiographs. The functional outcome was evaluated by Kona's system and Constant-Murley scoring system. RESULTS: All 30 cases showed bony union. By Kona's functional evaluation, there were 16 cases with excellent and good results in Group I and 14 cases in Group II. The average Constant score was 88.3 (71~100) in Group I and 89.6 (72~100) in Group II, but there was no significant difference in both groups. As complications, there were 2 case with subacromial impingement, and 1 case showed subacromial erosion. There was no K-wire migration, deep infection and acromioclavicular joint arthritis. CONCLUSION: Tension band and Hook plate fixation technique gave satisfactory clinical and radiological results in patients with type II distal clavicle fractures. These results suggest that tension band wire and Hook plate fixation technique seems to be an effective method for type II distal clavicle fracture. But we think thal early removal of plate is necessary due to risks for subacromial impingement and erosion in Hook plate fixation.

A Technique of Distal Clavicle Fracture Fixation Using The Tightrope Procedure

We present here a technique of fracture stabilization using the Tightrope procedure in a patient with a widely displaced Neer type IIB distal clavicle fracture. The Tightrope system, typically used for stabilization of acromioclavicular joint dislocation, has not been widely described for distal clavicle fractures. The patient achieved satisfactory results after surgery; we feel that this technique is appealing as it is simple, reproducible and avoids the complications associated with extensive metalwork. This technique may also appeal to the arthroscopic surgeon.

Mini-T Plate Fixation for Neer Type II Distal Clavicle Fracture

PURPOSE: To evaluate and report the clinical and radiological outcomes of open reduction and internal fixation with a mini-T plate for unstable distal clavicle fractures. MATERIALS AND METHODS: From December 2004 to July 2007, fifteen patients who had a fracture of the distal clavicle (Neer type II fracture) were treated with an open reduction and internal fixation using a mini-T plate. They were followed up for a minimum of one year and the clinical and radiological results were analyzed. RESULTS: The average time to fracture union was 3.1(3~4) months. There were no complications, such as deep infection or fixation loss. The mean ASES score was 97 points (85~100points) at the last follow up period, and 14 patients had a full range of motion of the shoulder. CONCLUSION: Open reduction and internal fixation with a mini-T plate for unstable distal clavicle fracture is a good surgical method with good clinical and radiological results.