Aims

Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA.

Osteoarthritis (OA) is the most common disorder of the Sternoclavicular Joint (SCJ). In our case-control study, we evaluated the relationship between clavicular length and OA at the SCJ. CT scans of adults presenting to the Emergency Department of our hospital were examined to look for OA, defined as the presence of osteophytes, subchondral cysts, or cortical sclerosis at the SCJ. Medial-most and lateral-most points of the clavicle were marked on the slices passing through the SC and AC joints respectively. Using x, y, and z-axis coordinates from the DICOM metadata, clavicular length was calculated as the distance between these two points with 3D geometry. Preliminary data of 334 SCJs from 167 patients (64% males, 36% females) with a mean age of 48.5 ± 20.5 years were analysed. Multivariate regression models revealed that age and clavicular length were independent risk factors for OA while gender did not reach statistical significance. A 1mm increase in length was associated with 9% and 7% reduction in the odds of developing OA on the left and the right respectively. Comparing the mean clavicular length using t-test showed a significantly shorter clavicle in the group with OA (145.8 vs 152.7, p=0.0001, left and 144.2 vs 150.3, p=0.0007, right). Our data suggest that the risk of developing OA at the SCJ is higher for shorter clavicles. This could be of clinical relevance in cases of clavicular fracture where clavicular shortening might lead to a higher risk of developing OA. Biomechanical studies are needed to find out the mechanism of this effect

Aims

Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK.

Aims

The aim of this study was to report the incidence of implant-related complications, further operations, and their influence on the outcome in a series of patients who underwent primary reverse total shoulder arthroplasty (RTSA).

Aims. 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. Methods. 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. Results. Data from the randomized controlled trial consisted of 86 patients who underwent operative fixation compared with 76 patients that united with nonoperative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient, was similar between each group at six weeks (operative 26.7% vs nonoperative 25.0%, p = 0.800), three months (52.3% vs 44.2%, p = 0.768), and six months post-injury (86.0% vs 90.8%, p = 0.349). The mean DASH score and return to work were also comparable at each timepoint. In the prospective cohort, 86.5% (n = 173/200) achieved union by six months post-injury (follow-up rate 88.5%, n = 200/226). Regression analysis found that no specific patient, injury, or fracture predictor was associated with an early return of function at six or 12 weeks. Conclusion. Return of normal shoulder function was comparable between acute plate fixation and nonoperative management when union was achieved. One in two patients will have recovery of normal shoulder function at three months, increasing to nine out of ten patients at six months following injury when union occurs, irrespective of initial treatment. Cite this article: Bone Jt Open 2021;2(7):522–529

Aims. The aim of this study was to define the complications and long-term outcome following adolescent mid-shaft clavicular fracture. Methods. We retrospectively reviewed a consecutive series of 677 adolescent fractures in 671 patients presenting to our region (age 13 to 17 years) over a ten-year period (2009 to 2019). Long-term patient-reported outcomes (abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and EuroQol five-dimension three-level (EQ-5D-3L) quality of life score) were undertaken at a mean of 6.4 years (1.2 to 11.3) following injury in severely displaced mid-shaft fractures (Edinburgh 2B) and angulated mid-shaft fractures (Edinburgh 2A2) at a minimum of one year post-injury. The median patient age was 14.8 years (interquartile range (IQR) 14.0 to 15.7) and 89% were male (n = 594/671). Results. The majority of fractures were mid-shaft (n = 606) with angulation (Edinburgh 2A2, n = 241/606, 39.8%) or displacement (Edinburgh 2B1/2, n = 263/606, 43.4%). Only 7% of the displaced mid-shaft fractures underwent acute fixation (n = 18/263). The incidence of refracture over ten years following nonoperative management of mid-shaft fractures was 3.2% (n = 19/588) and all united without surgery. Fracture type, severity of angulation, or displacement were not associated with refracture. One nonunion occurred following nonoperative management in a displaced mid-shaft fracture (0.4%, n = 1/245). Of the angulated fractures, 61 had angulation > 30°, of which 68.9% (n = 42/61) completed outcome scores with a median QuickDASH of 0.0 (IQR 0.0 to 0.6), EQ-5D-3L 1.0 (1.0 to 1.0), and 98% satisfaction with shoulder function. For the displaced fractures, 127 had displacement beyond one cortical width of bone for which completed outcome scores were provided in 72.4% (n = 92/127). Of these 15 had undergone acute fixation. Following nonoperative treatment, the median QuickDASH was 0.0 (IQR 0.0 to 2.3), EQ-5D-3L 1.0 (1.0 to 1.0), and satisfaction with shoulder function was 95%. There were no significant differences in the patients’ demography or functional outcomes between operative and nonoperative treatments. Conclusion. Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. Nonunion is exceptionally rare following nonoperative management and the relative indications for surgical intervention in adults do not appear to be applicable to adolescents. Cite this article: Bone Joint J 2021;103-B(5):951–957

Aims. To compare the functionality of adults with displaced mid-shaft clavicular fractures treated either operatively or nonoperatively and to compare the relative risk of nonunion and reoperation between the two groups. Methods. Based on specific eligibility criteria, 120 adults (median age 37.5 years (interquartile range (18 to 61)) and 84% males (n = 101)) diagnosed with an acute displaced mid-shaft fracture were recruited, and randomized to either the operative (n = 60) or nonoperative (n = 60) treatment group. This randomized controlled, partially blinded trial followed patients for 12 months following initial treatment. Functionality was assessed by the Constant score (CS) (assessor blinded to treatment) and Disability of the Arm, Shoulder and Hand (DASH) score. Clinical and radiological evaluation, and review of patient files for complications and reoperations, were added as secondary outcomes. Results. At 12 months, 87.5% of patients (n = 105) were available for analysis. The two groups were well balanced based on demographic and fracture-related characteristics. At six weeks of follow-up a significant difference in DASH score (p < 0.001) was found in favour of operative treatment. The functionality at 12 months of follow-up based on CS and DASH was excellent in both groups (CS > 90 points and DASH < 10 points) with no significant difference (p = 0.277 for DASH and p = 0.184 for CS) between the two groups. The risk of symptomatic nonunion was significantly higher in the nonoperative group (p = 0.014), with a relative risk of 9.47 (95% confidence interval (CI) 1.26 to 71.53) in this group compared to the operative group. The number-needed-to-treat to avoid one symptomatic nonunion was 6.2. Initial treatment and age were factors significantly associated with nonunion in a logistic analysis. There were 26% in both groups (n = 14 in operative group and n = 15 in nonoperative group) who required secondary surgery, with most indications in the nonoperative group mandatory due to nonunion compared to most relative indications in the operative group requiring intervention due to implant irritation. Conclusion. Superiority was not identified with either an all-operative or all-nonoperative approach. The functionality at short term (within six weeks) seems igreater following operative treatment but was not found at one year. The risk of nonunion is significantly higher with nonoperative treatment. However, an all-operative approach to lower the nonunion risk may result in unnecessary surgery and is not recommended. Cite this article: Bone Joint J 2021;103-B(4):762–768

Aims. The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery. Patients and Methods. A retrospective case series was undertaken of all displaced clavicular fractures that underwent plate fixation over a ten-year period (2007 to 2017). Patient demographics, time to surgery, complications, and mode of failure were collected. Logistic regression was used to identify independent risk factors contributing towards operative complications. Receiver operating characteristic (ROC) curve analysis was used to determine if a potential ‘safe window’ exists from injury to delayed surgery. Propensity score matching was used to construct a case control study for comparison of risk. Results. A total of 259 patients were included in the analysis. Postoperative infection occurred in 3.9% of all patients (n = 10); the only variable associated was a greater time interval from injury to fixation (p = 0.001). Failed primary surgery requiring revision fixation was required in 7.7% of the cohort (n = 20), with smoking (p < 0.001), presence of a postoperative infection (p < 0.001), increasing age (p = 0.018), and greater time delay from injury to surgery (p = 0.015) identified as significant independent predictors on regression analysis. ROC analysis revealed that surgery beyond 96 days from injury increased the rate of major complications and revision surgery. Using a matched case cohort of cases before (n = 67) and after (n = 77) the ‘safe window’, the risk of postoperative infection increased (odds ratio (OR) 7.7, 95% confidence interval (CI) 1.9 to 62.9; p = 0.028), fixation failure (OR 3.8, 95% CI 1.2 to 12.1; p = 0.017) and revision surgery (OR 4.8, 95% CI 1.5 to 15.0; p = 0.004). Conclusion. A delay to primary fixation of up to three months following injury may be acceptable, beyond which there is an increased risk of major operative complications and revision surgery. Cite this article: Bone Joint J 2019;101-B:1385–1391

Aims

The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures.

Aims

Recent studies of nonoperatively treated displaced midshaft clavicular fractures have shown a high incidence of nonunion and unsatisfactory functional outcome. Some studies have shown superior functional results and higher rates of healing following operative treatment. The aim of this study was to compare the outcome in these patients after nonoperative management with those treated with fixation.

Background. Level 1 studies for fracture management of upper extremity fractures remains rare. The influence of these studies on management trends has yet to be evaluated. The purpose of this study was to examine alterations in national trends managing mid-shaft clavicle and intra-articular distal humerus fractures (DHF) surrounding recent Level 1 publications. Methods. We retrospectively reviewed a comprehensive Medicare (2005–2012) and Humana (2007–2014) patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for DHF and mid-shaft clavicle fractures, respectively. Non-operative management and open reduction internal fixation (ORIF) were reviewed for mid-shaft clavicle fractures. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. Total use and annual utilization rates were investigated using age limits defined in the original Level 1 studies. Results. A total of 4,929 clavicle patients between 15 and 59 years, and 106,535 DHF patients greater than 65 years of age were coded. There was no significant change in annual volume of mid-shaft clavicle fractures and DHF coded (p=0.078 and p=0.614, respectively). Among clavicle patients there was a significant increase in ORIF utilization following the publication of the Level 1 study (p=0.002), and a strong, positive correlation was evident (p=0.007). No significant change in annual TEA (p=0.515) utilization for DHF was seen. Conclusion. A significant increase in the utilization of ORIF for clavicular fractures was observed following the publication of supporting Level 1 evidence. This was not observed following similar evidence in managing DHF, as no increase in utilization of TEA was observed

Clavicular hook plates have been used over the last decade in the treatment of lateral clavicular fractures with good rates of union reported throughout the literature. Fewer studies have reported the functional outcome of these patients and some have reported potential soft tissue damage post plate removal. We aimed to review the functional outcomes alongside union rates in patients treated with hook plates for lateral clavicular fractures. In this retrospective case series, 21 patients with traumatic lateral third clavicular fractures were included. 15 had Neer type II fractures, 4 Neer type III fractures, 1 patient had a Neer type I fracture and 1 radiograph was not able to be classified. All patients were treated with clavicular hook plates at the same district general hospital by five experienced surgeons between March 2010 and February 2015 adhering to the same surgical protocol. All patients had standard physiotherapy and post operative follow up. Plates were removed when radiological union was achieved in all but one patient who had the plate removed before union was achieved due to prolonged non-union. Patients were followed up post plate removal and evaluated clinically using the Oxford Shoulder Score. Their post plate radiographs were assessed by an independent radiologist and bony union documented. 21 patients were included. Mean age was 40 (range 14–63) with a male:female ratio of 17:4. Mean follow up was 5 months post injury (1–26 months). The hook plate remained in situ for a mean time of 4.3 months (2–16 months). One patient developed a post-operative wound infection treated with antibiotics, 2 patients developed adhesive capsulitis, one patient had not achieved bony union prior to hook plate removal at 16 months, however did achieve union 2 months post plate removal, two patients required revision plating. All patients achieved bony union eventually with good alignment and no displacement of the acromioclavicular joint seen on the most recent post operative radiographs. Post plate removal Oxford Shoulder Scores indicated good shoulder function with a mean score of 41.5 (maximum score possible 48 and the range of scores for our cohort was 30–47). Our data would support the use of hook plates in the treatment of lateral clavicular fractures. All patients achieved union eventually with good alignment and this was reflected in the good functional outcome scores. This study is limited in its small cohort and short-term follow up. More research is required to examine the long term consequences of hook plate surgery in a larger patient population

Aims

To compare radiographic failure and re-operation rates of anatomical coracoclavicular (CC) ligament reconstructional techniques with non-anatomical techniques after chronic high grade acromioclavicular (AC) joint injuries.

Only a few randomised, controlled studies have compared different non-operative methods of treatment of mid-shaft fractures of the clavicle.

In this prospective, randomised controlled study of 60 participants (mean age 31.6 years; 15 to 75) we compared the broad arm sling with the figure of eight bandage for the treatment of mid-shaft clavicle fractures. Our outcome measures were pain, Constant and American Shoulder and Elbow Surgeons scores and radiological union.

The mean visual analogue scale (VAS) pain score on the first day after treatment was significantly higher (VAS 1 6.8; 4 to 9) in the figure of eight bandage group than the broad arm sling group (VAS 1 5.6; 3 to 8, p = 0.034). A mean shortening of 9 mm (3 to 17) was measured in the figure of eight bandage group, versus 7.5 mm (0 to 24) in the broad arm sling group (p = 0.30).

The application of the figure of eight bandage is more difficult than of the broad arm sling, and patients experience more pain during the first day when treated with this option. We suggest the broad arm sling is preferable because of the reduction of early pain and ease of application.

Cite this article: Bone Joint J 2015;97-B:1562–5.