Tailoring surgical management of dislocated clavicle fractures

Abstract

In this thesis literature research and clinical studies are presented to assist physicians in the decision making process for surgical treatment of dislocated midshaft clavicle fractures (DMCF). In Chapter 1 an introduction is given regarding the background, aim and outline of this thesis. Chapter 2 is a systematic review comparing plate fixation and intramedullary fixation for DMCF. The quality of evidence of each included study is evaluated using two different quality-scoring systems. All four included studies report no significant difference in function or complications. Despite the limited number and low quality of the available studies, there is no difference in shoulder function between patients treated with plate fixation or intramedullary fixation for DMCF.

Chapter 3 specifically focuses on the complications after plate fixation. Another literature search is performed and a total of eleven studies are found. Quality tools are used to qualify the included studies. Complications are divided into two groups: major and minor complications. Only three studies are of high quality evidence. With regards to major complications plate fixation is a safe treatment option for DMCF but implant related complications are relatively frequent.

In Chapter 4 the same approach is used to assess the complications following intramedullary fixation for DMCF. A total of six studies are included and analyzed. This chapter shows that intramedullary fixation is a safe treatment option for DMCF. The advantage of intramedullary fixation is that revision or removal of the implant can be performed minimally invasive with small incisions and short operating times. Minor complications (medial protrusion) occur frequently. As a result of routine implant removal, treatment with intramedullary fixation requires an additional surgical procedure.

In Chapter 5 a retrospective comparison of plate fixation and intramedullary fixation using a titanium elastic nail (TEN) is presented focussing on complications. Records of 90 patients who were treated with either plate fixation or intramedullary fixation are reviewed and complications are reported. This chapter shows a tendency towards more major complications (implant failure and refracture after implant removal) after plate fixation in comparison with intramedullary fixation. Minor complications (medial protrusion) are more frequent after intramedullary fixation.

After comprehensive literature and retrospective research for the optimal surgical treatment of DMCF, Chapter 6 presents the rationale and design of a multicentre prospective randomized trial comparing plate fixation with intramedullary fixation (pin or plate: POP-study). Short-term results of the POP-study are presented in Chapter 7. A total of 120 patients were included and treated according to block-randomization with either plate fixation or intramedullary fixation using TEN. Operative time, post-operative pain, shoulder function scores and complications were documented up until six weeks post-operatively. This chapter reports better functional results of the shoulder six weeks postoperatively favouring plate fixation. More complications are seen in the TEN-group but the time of surgery is significantly shorter. This thesis provides a solid basis for future research of the surgical treatment of DMCF and concludes that both plate fixation and intramedullary fixation are safe treatment options for DMCF