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Currently, open reduction–internal fixation using contoured plates or intramedullary nails is considered the standard operative treatment for midshaft clavicle fractures because of the immediate rigid stability provided by the fixation device. In addition, autologous iliac crest bone graft has proved to augment osteosynthesis during internal fixation of nonunion fractures through the release of osteogenic factors. The purpose of this article is to describe a surgical technique developed to reduce donor-site morbidity and improve functional and objective outcomes after open reduction–internal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.
Technique Video
See video under supplementary data.
The clavicle is one of the most commonly fractured bones, representing 5% to 15% of all fractures.
Fractures of the midshaft account for approximately 80% of all clavicular fractures because the junction between the lateral and middle third is the thinnest portion of the bone and lacks muscular and ligamentous reinforcement.
Historically, fractures of the middle third of the clavicle were managed nonoperatively because closed treatment was believed to yield a low nonunion rate and minimal functional impairment.
In addition, clavicular malunion, which occurs to some degree in approximately two-thirds of midshaft clavicle fractures, was previously described as being solely a radiographic anomaly with no clinical significance.
However, more recent studies have suggested that operative treatment results in increased patient satisfaction, superior functional capabilities, and decreased rates of nonunion and malunion when compared with nonoperative management.
Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial.
Currently, open reduction–internal fixation is considered the gold-standard treatment because of the immediate rigid stability provided by the fixation device.
Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial.
In addition, autologous iliac crest bone graft (ICBG) has proved to augment osteosynthesis during fixation of nonunion fractures through the release of osteogenic factors.
Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial.
However, studies have associated ICBG harvesting with significant donor-site morbidity, including neurologic and vascular injury, incisional hernia, donor-site fracture, and deep infection.
Therefore, the purpose of this article was to describe a surgical technique developed to reduce donor-site morbidity and improve functional outcomes after open reduction–internal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.
Technique
This technical note describes open reduction–internal fixation of a midshaft clavicle fracture with autologous bone graft placement through local autograft harvest and plate fixation (Video 1). Pearls and pitfalls of this technique are described in Table 1, and advantages and limitations are presented in Table 2.
Table 1Pearls and Pitfalls of Surgical Technique
Pearls
Minimize destruction of the periosteum and the soft-tissue envelope around the clavicle to facilitate healing.
Use a high drilling speed and large drilling force to minimize the increase in bone temperature.
Avoid preserving bone autograft in saline solution because this will wash away osteogenic growth factors.
Table 2Advantages and Limitations of Surgical Technique
Advantages
Reduced operating time and operating costs because of the lack of a secondary incision for iliac crest autograft harvest
No second-incision donor-site morbidity
Improved osteosynthesis because of the presence of osteogenic factors in the autograft
Limitations
Possibility of yielding less bone autograft than an iliac crest bone autograft
Risk of heat-induced osteonecrosis due to pilot-hole drilling, which may cause breakdown of the bone around the implantation site, leading to fixation loosening
The patient is placed in the beach-chair position with the axilla and hand excluded from the surgical field. A 10-cm incision is made with a No. 15 scalpel blade superior to the site of clavicle injury in concordance with the Langer lines (Fig 1).
Fig 1The patient is placed in the beach-chair position (left shoulder) with the axilla and hand excluded from the surgical field. A 10-cm incision is made with a No. 15 scalpel blade superior to the site of clavicle injury.
Once the fracture is identified through sharp dissection, a cortical read is obtained by removing the most minimal amount of soft tissue to preserve the soft-tissue envelope around the fracture site (Fig 2). After soft-tissue mobilization and visualization of the clavicular pathology, the clavicle fracture is provisionally reduced using bone reduction forceps to facilitate the selection of an appropriately sized fixation plate (Fig 3, Fig 4, Fig 5).
Fig 2Sharp dissection is performed with a No. 15 scalpel blade to allow for visualization of the fracture site. A minimal amount of soft tissue is removed to preserve the soft-tissue envelope around the fracture site (left shoulder).
Fig 3Bone reduction forceps are used to provisionally reduce the butterfly fragment in preparation for precontoured fixation plate sizing (left shoulder).
Fig 4In this particular case, a K-wire is drilled into the superior aspect of the butterfly fragment to ensure the stability of the reduced fragment (left shoulder).
Fig 5In this patient, an 8-hole precontoured titanium plate is used based on the length of the clavicle and extent of the pathology (left shoulder). The plate size is selected so that 4 cortices are drilled on each side of the fracture site.
When plate fixation is being performed, a precontoured titanium plate (Acumed, Hillsboro, OR) is used based on the length of the clavicle and extent of the pathology. The plate length is selected so that 4 cortices are drilled on either side of the fracture site. With the plate as a guide, a 2.8-mm drill bit (Acumed) is used to ream pilot holes in preparation for screw placement (Fig 6). To minimize the risk of osteonecrosis, all drilling is performed at maximum revolutions per minute. In addition, irrigation is applied to the drill bit before initiation and during drilling to reduce heat aggregation. To avoid washing away osteogenic factors from the bone autograft, irrigation is not applied during the removal of the drill bit from the bone.
Fig 6With the precontoured plate used as a guide, a 2.8-mm drill bit is used to ream pilot holes in the superior aspect of the clavicle in preparation for screw placement (left shoulder).
After drilling of each pilot hole, the bony remnants are collected from the flutes of the drill bit (Fig 7) with a dental pick. In addition to those from the drill flutes, any bony remnants that accumulate adjacent to the drilling site are collected and preserved with the others in a sterile cup (without saline solution) while awaiting placement within the fracture site (Fig 8).
Fig 7A dental pick is used to harvest bone autograft from the flutes of the drill bit after the drilling of each pilot hole.
Fig 8After harvesting of the bone autograft from the flutes of the drill bit, the autograft is placed in a sterile cup (with no saline solution) for preservation. Saline solution is not added to the cup to avoid washing away important osteogenic factors contained within the autograft.
Before plate fixation, a surgical depth-measurement device (Sklar, West Chester, PA) is used to determine the depth of each pilot hole (Fig 9). Once the plate has been fixed and the depth measurements determined, screws (Acumed) are placed in either a corticocancellous locking or non-locking configuration (Fig 10).
Fig 9A surgical depth-measurement device is used to determine the depth of the medial pilot hole before screw placement (left shoulder).
Fig 10A screwdriver (Acumed) is used to place screws in a laterally located pilot hole (left shoulder). The screws are placed in either a corticocancellous locking or non-locking configuration.
Irrigation is applied after fluoroscopy to clean the fracture site. Then, the accumulated bone autograft is packed within the posterior aspect of the fracture site with a forceps (Fig 12). After placement of the bone autograft, the incision is closed with a focus on preservation and repair of the periosteum and soft-tissue envelope. The patient's extremity is immobilized for 2 weeks in a sling, followed by a gradual return to motion.
Fig 12The bone autograft that accumulated in the sterile cup (Fig 8) is packed within the posterior aspect of the fracture site with a forceps (left shoulder).
Open reduction–internal fixation with the implementation of either contoured plates or intramedullary nails is a commonly used technique for midshaft clavicular fracture fixation.
Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial.
In instances in which the indication for surgical treatment is fracture nonunion, autologous ICBG may be added to provide a scaffolding for growth and facilitate osteosynthesis.
Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial.
However, studies have associated ICBG harvesting with significant donor-site morbidity. Therefore, the purpose of this article was to describe a surgical technique developed to reduce donor-site morbidity and improve functional outcomes after open reduction–internal fixation with autologous bone graft placement through local autograft harvesting and concurrent plate fixation.
The primary advantage of this technique is that it eliminates the need for ICBG harvesting, reducing the risk of associated second-incision donor-site morbidity, such as neurovascular injury, incisional hernia, donor-site fracture, and deep infection.
In addition, because of the lack of a secondary incision for iliac crest autograft harvest, the time spent in the operating room and total operating costs are reduced. This surgical technique has been used for 6 years, yielding favorable postoperative complication and union rates.
The primary limitation of this technique is that it may yield less bone autograft than an ICBG. However, further research is warranted because there is currently no literature regarding the quantity of bone graft obtained from the iliac crest during autograft harvesting. An additional potential disadvantage inherent to all fracture treatment strategies involving bone drilling is heat-induced osteonecrosis, which causes breakdown of bone around the implantation site leading to loosening of the fixation.
Nevertheless, this procedure aims to make the best use of drilling by applying autograft tissue that may otherwise be discarded.
Heat-induced osteonecrosis is an important factor to minimize in this technique to maintain the viability of the bone graft. Before rigid fixation of the contoured plate, a drill bit is used to create pilot holes in the bone to reduce the likelihood of further bone fracture during cortical screw placement. During the bone-drilling process, the temperature within the bone adjacent to the drill site rises, which can result in osteonecrosis.
The exact threshold temperature for osteonecrosis in human cortical bone is not known. However, most investigators studying the topic of bone necrosis have agreed that an average temperature of 47°C for 1 minute serves as a threshold above which the necrosis of human bone occurs.
suggested that the temperature generated during bone drilling is dependent on variables including drill bit diameter, drill revolutions per minute, axial drilling forces, and irrigation. Although there is no clear indication about the optimum drilling speed or force from past studies, most investigators have recommended a high drilling speed and large forces for minimum temperature generation, although drilling forces should be tempered to reduce to risk of lung puncture or neurovascular injury. In addition to providing drilling recommendations, investigators have asserted that irrigation (internal or external) is the most important factor in avoiding bone necrosis.
However, it has been suggested that external irrigation may reduce effective osteosynthesis by washing away important osteogenic growth factors surrounding the fracture site.
The described surgical technique is a safe, effective, and reproducible approach to treating midshaft clavicle fractures. We recommend our method of reduction and fixation for clavicle fractures and encourage further studies to investigate and assess our technique.
Acknowledgment
The authors thank Chris Jacobsen and Barry Eckhaus for their expertise in producing and editing the multimedia components contained within this article.
The patient is placed in the beach-chair position, and a 10-cm incision is made superior to the site of clavicle injury (left shoulder). Sharp dissection is performed to allow for visualization of clavicle pathology. After visualization of the fracture site, provisional reduction is performed in preparation for precontoured fixation plate sizing. In this case, a K-wire was used to ensure stability of the reduced butterfly fragment. An 8-hole precontoured titanium plate is placed superior to the fracture site. The precontoured plate is used as a guide for pilot hole drilling, which is performed with a 2.8-mm drill bit. After each pilot hole is drilled, a dental pick is used to collect the bony fragments from the flutes of the drill bit. The bone autograft is placed in a sterile cup (with no saline solution) for preservation. A surgical depth-measurement device is used to determine the depth of the pilot holes, and screws are placed for final precontoured plate fixation. Fluoroscopy is used to confirm the position and length of the screws. Before closure, the bone autograft is placed within the posterior aspect of the fracture site with a forceps. Once the autograft has been placed, a standard closure is completed.
References
Zehir S.
Akgül T.
Zehir R.
Results of midshaft clavicle fractures treated with expandable, elastic and locking intramedullary nails.
Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial.
The authors report the following potential conflict of interest or source of funding: T.R.H. receives support from Arthrex, Sonoma Orthopaedics, and NICE. This article was funded internally by the Steadman Philippon Research Institute.
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