It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management. Patient data from a randomized controlled trial were used to compare acute plate fixation with nonoperative management of united fractures. Return of shoulder function was based on the age- and sex-matched Disabilities of the Arm, Shoulder and Hand (DASH) scores for the cohort. Independent predictors of an early recovery of normal shoulder function were investigated using a separate prospective series of consecutive nonoperative displaced mid-shaft clavicular fractures recruited over a two-year period (aged ≥ 16 years). Patient demographics and functional recovery were assessed over the six months post-injury using a standardized protocol.Aims
Methods
The aim of this study was to determine if the extent of the glenoid and humeral bone loss affects the rate of recurrent instability and the functional outcome following the Latarjet procedure. 161 patients underwent open Latarjet procedure during the period 2006–2015 (Mean age 30.0 years, 150t (93.2%) Male, 118 (73.3%) primary procedure). Functional outcome was measured using the Western Ontario Shoulder Instability Index (WOSI) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDash) score at a mean of 4.7 years post-operatively. All patients underwent computed tomographic (CT) imaging pre-operatively. Using three-dimensional reconstruction, the glenoid bone loss, Hill-Sachs lesion and ‘Glenoid Track’ status was recorded. Radiographically-confirmed redislocation was rare (1.2%), but 18.5% (n=23/124) reported ongoing subjective shoulder instability. Fifty-two shoulders (32.3%) were classified as “Off-Track”. The median Quick DASH and WOSI scores were 2.27 (IQR 9.09; range 0–70.45) and 272.0 (IQR 546.5; range 0–2003), respectively. There were no significant differences observed between overall Quick DASH scores or WOSI scores for either On-Track or Off-Track groups (p=0.7 and 0.73, respectively). Subjective instability was not influenced by the degree of glenoid bone loss (p=0.82), the overall size of the Hill-Sachs lesion (p=0.80), or the presence of an ‘Off-Track’ lesion (p=0.84). Functional outcome and recurrent instability following the Latarjet procedure do not appear to be influenced by the extent of glenohumeral bone loss prior to surgery.
This multi-centre single-blind randomised control trial compared outcomes in patients with acute displaced mid-shaft clavicle fractures treated either by primary open reduction and plate fixation (ORPF), or non-operative treatment (NT). Two-hundred patients were randomised to receive either ORPF or NT. Functional assessment was conducted up to one-year using DASH, SF-12 and Constant scores (CS). Union was evaluated using radiographs and CT. Rate of non-union was significantly reduced after ORPF (1 following ORPF, 16 following NT, odds ratio=0.07, 95% CI=0.01–0.50, p=0.0006). 7 patients had delayed-union after NT. Group allocation to ORPF was independently predictive of development of non-union. DASH and CS were significantly better in the ORPF group 3-months post-surgery, but not at one-year (mean DASH = 6.2 after NT versus 3.7 after ORPF, p=0.09; mean CS = 86.1 after NT versus 90.7 after ORPF, p=0.05). Group allocation was not predictive of one-year outcome. Non-union was the only factor independently predictive of one-year functional outcome. There were no significant differences in time off work or subjective scores. Five patients underwent revision for complications after ORPF. 10 patients underwent metalwork removal. Treatment cost was significantly greater after ORPF (p=0.001). ORPF reduces rate of non-union compared with NT and is associated with better early functional outcomes. Improved outcomes are not sustained at one-year. Differences in functional outcome appear to be mediated by prevention of non-union from ORPF. ORPF is more expensive and associated with implant-related complications not seen with NT. Our results do not support routine primary ORPF for displaced mid-shaft clavicle fractures.
