Abstract
This thesis compares the biomechanical and clinical aspects of two popular surgical techniques for the operative treatment of displaced midshaft clavicle fractures (DMCF): Plate Fixation (PF) and IntraMedullary Fixation (IMF). Biomechanical Comparison The exact implications of different types of fracture fixation on direct post-operative rehabilitation are not clear in the
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literature due to a lack of solid physiologic data and variation in methodology. PF, particularly compression plates, makes a more robust construct than the ‘traditional’ IM devices in terms of stiffness and failure loading. A benefit of IM devices is that after removal following fracture union, the remaining clavicle is stronger than after plate removal. In a pilot study, no evidence was found that alterations in scapulothoracic kinematics were present one year after surgical fixation of a DMCF by either technique. Two experts clinically evaluated operated and contralateral shoulders of patients and also a healthy control group. The low inter-observer reliability and limited agreement between expert evaluations and actual patient or control status additionally indicated the difficulty in visually detecting gross scapulothoracic dyskinesia. Clinical outcome In the Plate or Pin (POP) study, 120 patients with a DMCF were treated with anterosuperior PF or antegrade IMF. Recovery was faster in the PF group, with a 55% recovery rate at 6 weeks after surgery according to the DASH score. However, at one year after surgery results were similar (mean DASH score 2.9 after PF and 3.9 after IMF). The rate of complications was high for both surgical techniques, in particular due to implant related soft tissue irritation (42% after PF and 54% after IMF). The rate of patients requiring revision surgical fixation, due to for instance nonunion or implant failure, was 7% after PF and 3% after IMF. The Surgical Therapeutic Index (STI) allows for ease comparison of the benefits and adverse sides of different surgical techniques; the higher a procedure’s STI, the higher the benefit/risk balance of that procedure. When determining the indices of PF and IMF, a significant difference in favor of PF was observed during the early phase of recovery, which was prolonged when correcting for the gravity of consequences of complications. One year postoperatively, the STI for PF and IMNF were similar. Treatment recommendations In general PF is preferred over IMF. The fixation construct is more rigid allowing for early functional rehabilitation and both objective and subjective recovery is faster. IMF seems technically more challenging with high rates of implant related soft tissue irritation confirming the general consensus that the implant is better to be removed as a matter of routine following fracture healing. Future perspectives Future studies might wish to focus on the influences of different surgical repair techniques on specific activities of daily living directly after surgery. Other challenges ahead mainly lie in diminishing the complications of surgical fixation and, regarding IMF, identifying pre-operative risk factors for implant related soft tissue irritation. Finally, the STI may be a reliable tool for the assessment of potential benefits and risks of operative fracture management but requires further investigation.
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