The American Journal of Sports Medicine http://ajs.sagepub.com/
Return to Sports After Plate Fixation of Displaced Midshaft Clavicular Fractures in Athletes Maximiliano Ranalletta, Luciano A. Rossi, Nicolás S. Piuzzi, Agustin Bertona, Santiago L. Bongiovanni and Gaston Maignon Am J Sports Med 2015 43: 565 originally published online December 9, 2014 DOI: 10.1177/0363546514559913 The online version of this article can be found at: http://ajs.sagepub.com/content/43/3/565
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On behalf of: American Orthopaedic Society for Sports Medicine
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In-Depth
Return to Sports After Plate Fixation of Displaced Midshaft Clavicular Fractures in Athletes Maximiliano Ranalletta,* MD, Luciano A. Rossi,*y MD, Nicola´s S. Piuzzi,* MD, Agustin Bertona,* MD, Santiago L. Bongiovanni,* MD, and Gaston Maignon,* MD Investigation performed at the Italian Hospital of Buenos Aires, Buenos Aires, Argentina Background: Recent prospective randomized trials support primary plate fixation of displaced midshaft clavicle fractures. However, the safety and efficacy of this practice have not been well documented in athletes, nor has the time to return-to-sport. Purpose: To analyze the time to return-to-sport, functional outcomes, and complications in a group of athletes with displaced midshaft clavicle fractures treated using precontoured locking plates. Study Design: Case series; Level of evidence, 4. Methods: A total of 54 athletes with displaced midshaft clavicle fractures were treated with plate fixation between November 1, 2008, and December 31, 2012. The mean follow-up time was 22.4 months. Patients completed a questionnaire focused on the time to return-to-sport and treatment course. Functional outcomes were assessed with the Constant score and short version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Pain was evaluated with the visual analog scale (VAS). Radiographs were reviewed to identify radiographic union time, malunion, and nonunion. Results: Of the 54 patients, 53 returned to sports after open reduction and internal fixation of their fracture; 94% returned to the same level. The mean time to return-to-sport was 68 days (range, 5-180 days). Nine (16.6%) of the cases returned to sports before 6 weeks after surgery, 40 (74%) returned between 6 and 12 weeks, and 5 patients (9.2%) returned 12 weeks after surgery. The mean Constant score was 94.1 6 5.2 (range, 78-100), and the mean QuickDASH score was 0.4 6 4.7 (range, 0-7.1). The mean VAS pain score during follow-up was 0.29 6 1.0 (range, 0-5). Three major complications occurred: 1 extrinsic compression of the subclavian vein, 1 nonunion, and 1 hardware loosening. Hardware removal was necessary in 5 patients (9.3%). Conclusion: Plate fixation of displaced clavicle fractures in athletes is a safe procedure resulting in excellent functional outcomes, with an early return to the same level of sports in the majority of patients. Keywords: athletes; clavicular fractures; plate fixation
Clavicle fractures are common injuries and account for approximately 2.6% to 5% of all fractures in adults.13,14 Middle-third fractures are the most common type (80%). The latter are displaced in 48% of cases and comminuted in 19%.13,14 The most common mechanism for a clavicular fracture is a fall onto the ipsilateral shoulder, making athletes particularly prone to this injury.17 Traditionally, nonsurgical management has been favored as the treatment for most clavicular fractures.12,15 However,
recent evidence has emerged indicating that operative fixation presents lower nonunion rates, better functional outcomes, improved cosmesis, and greater patient satisfaction compared with closed treatment.2 Hill et al6 reported the results of 52 patients with completely displaced midshaft clavicular fractures treated nonoperatively and showed a 15% incidence of nonunion and 31% unsatisfactory results. Several recent prospective randomized clinical trials that compared nonoperative treatment with open reduction and internal fixation (ORIF) with plate fixation showed that operative treatment improved functional outcomes and significantly decreased the incidence of longterm complications such as nonunion and symptomatic malunion.2,11,16,19 Consequently, there has been a trend in the past few years to increase operative treatment. As this injury usually affects young, active patients, the treatment objective is to obtain early union and subsequently a rapid return to prior function. Favorable results with surgical treatment for middle-third clavicular fractures have been reported,9,11,19 however there is a lack of published literature referring to clinical outcomes in
y Address correspondence to Luciano A. Rossi, MD, Institute of Orthopedics ‘‘Carlos E. Ottolenghi,’’ Italian Hospital of Buenos Aires, Potosi 4247, CIP: 1199 Buenos Aires, Argentina (e-mail: luciano.rossi@ hospitalitaliano.org.ar). *Institute of Orthopedics ‘‘Carlos E. Ottolenghi,’’ Italian Hospital of Buenos Aires, Buenos Aires, Argentina. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 43, No. 3 DOI: 10.1177/0363546514559913 Ó 2014 The Author(s)
565 Downloaded from ajs.sagepub.com at Harvard Libraries on June 26, 2015
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TABLE 1 Demographic and Fracture-Related Characteristicsa Variable Sex Male Female Age, y, mean 6 SD Dominant arm No Yes Edinburgh classification Subtype B1 Subtype B2 Mechanism of injury Sports Motorcycle Fall Car accident Bicycle Other Pre-injury sport level Competitive Recreational
47 (87) 7 (13) 30.1 6 10.8 23 (43) 31 (57) 38 (70) 16 (30) 25 12 6 5 4 2
(46) (22) (11) (9) (7) (4)
29 (54) 25 (46)
a
Data are presented as n (%) unless otherwise indicated.
athletes with this injury and the ideal time required to return to sport.10,18 It has become our usual practice to perform ORIF of displaced midshaft clavicular fractures in athletes. We hypothesized that ORIF of displaced clavicular fractures in athletes is a safe and effective procedure, resulting in a reliable and timely return to play. The aim of this study was to analyze the time to return-to-sport, functional outcome, and complications of a group of athletes with displaced midshaft clavicular fractures treated using precontoured locking plates.
MATERIALS AND METHODS Between November 1, 2008, and December 31, 2012, we performed ORIF of displaced midshaft clavicular fractures on 54 clavicular fractures in 54 athletes. In all cases, internal fixation by precontoured plates (Acumed) with angular stability was used. Inclusion criteria were as follows: patients with closed type 2B fractures according to Edinburgh classification, timeframe within 3 weeks from injury, and age between 16 and 60 years. Patients were required to have an intention to return to sports postoperatively. Indications for ORIF were displaced or comminuted clavicular fracture. The ethics committee of the Italian Hospital of Buenos Aires approved this study (IRB: 00003580). Patient demographic and fracture characteristics are listed in Table 1. During the surgical procedure, patients received combined anesthesia (regional blockade 1 general anesthesia) and were placed in the beach-chair position with a pad behind the ipsilateral scapula. An anteroinferior approach centered in the fracture site was chosen in all cases. Once
Figure 1. One-month postoperative radiographs (45° uptilted anteroposterior). Open reduction and internal fixation with a 7-hole precontoured locking plate using 6 screws, 3 lateral and 3 medial, to focus. The patient started training 3 weeks after fracture and returned to competition 6 weeks after fracture. anatomic fracture reduction was achieved, we proceeded with internal fixation. The plate was placed on the clavicle superior side (Figure 1). In the presence of a third fragment we chose to place 1 or more interfragmentary screws. Plates with different number of holes and different amount of screws were used, with a minimum of 3 bicortical screws on each side of the fracture (Figure 1). After plating was completed, routine layered closure was accomplished. Once the procedure was over, radiological control was made at the operating room. Patients were discharged the same day or the day following surgery. Postoperative rehabilitation protocol consisted of arm sling during the first 2 postoperative weeks, with sling removal 4 times a day to perform pendulum exercises. Patients were not allowed to elevate the surgical arm above 90° in any plane during the first 3 weeks and were told to avoid lifting heavy weights for the first 6 weeks. After week 8, full shoulder active range of motion in all planes was allowed, with increase in intensity of strength and functional training for gradual return to activities and sports. Although clear instructions were given, we often observed that patients did not follow them. Clinical and radiological evaluation was performed during follow-up the first month weekly and then monthly until fracture consolidation was reached. Radiological evaluation consisted of frontal clavicle radiograph and a 45° up-tilted anteroposterior radiograph (Figure 2). Fracture consolidation was evaluated through clinical examination and through radiological analysis (looking for at least 3 consolidated corticals in 2 incidences). Functional outcome was evaluated using the Constant score3 and the short version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score.7 Residual pain was tested using the visual analog scale (VAS), with 0 indicating no pain and 10 maximum pain. All surgeryrelated complications and reoperations were documented. Patients were also asked if they had been able to practice their previous sports and if they had been able to perform them at the same level they had before the fracture.
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Figure 2. A 22-year-old male patient with football trauma. He had an Edinburgh type 2B-1 (simple, displaced) fracture. Patient sport level was divided into competitive sport (regular sport with competition and practice .2 times per week) and recreational sport (regular sport without competition \2 times per week). The distinctive types of shoulder-dependent sport were subdivided in an analog manner according to Allain et al1: noncollision/nonoverhead shoulder sport (G1), high-impact/collision sport (G2), overhead sport (G3), and martial arts sport (G4). Patients were allowed to return to sports when radiographic and clinical fracture union had occurred, full shoulder range of motion had been achieved, and shoulder strength was near 100%. When plate removal was required, we only restricted sports practice for 4 to 6 weeks in patients who practiced high-impact/collision sports (G2) to allow bone growth in the screw holes.
Statistical Methodology Continuous variables are presented as mean 6 SD, whereas categorical variables are given as absolute and relative frequencies. Statistical analysis was performed using the software STATA version 12 (Stata Corp).
RESULTS No patient was lost for follow-up, thus the analysis was made up of 54 fractures in 54 patients (Table 1); 47 patients were male (87%) and 7 (13%) were female, with a mean age of 30.1 6 10.8 years. There were 29 fractures on the left side and 25 on the right side; 31 (57%) were on the dominant side. All fractures were classified to group 2B according to the Edinburgh classification; specifically, 38 subtype B1 and 16 subtype B2 fractures were identified. None of these were open fractures, nor were they accompanied by neurovascular lesions at the time of surgery. The main cause of fracture was sport-related trauma (25 cases; 46%) with motorcycle-related accidents being the second most common cause (12; 22%) (Table 1). No patient was admitted to the intensive care unit. Five patients had associated lesions (1 tibial plateau fracture, 1 ankle fracture, 1
Figure 3. Percentage of patients who returned to sports after surgery. costal fracture, 1 midshaft humeral fracture, and 1 distal radius fracture), however none of them had a life-threatening condition. The mean elapsed time between fracture and surgery was 6.9 6 3.0 days (range, 2-12 days). The mean surgery time was 74.2 minutes (range, 43-117 min). There were no intraoperative complications. Mean follow-up was 22.4 6 19.6 months (range, 14-49 months). Fifty-three (98.1%) fractures consolidated. The mean Constant score was 94.1 6 5.2 (range, 78-100), the mean QuickDASH score was 0.4 6 4.7 (range, 0-7.1), and the mean VAS pain score was 0.29 6 1.0 (range, 0-5) at final follow-up. Of the 54 patients, 53 (98.1%) were able to return to sports. The patient who did not manage to return to sports had a concomitant tibial plateau fracture and attributed inability to resume sports to knee pain. The mean time to return to play was 68 days (10 weeks), with a range of 5 to 180 days; 16.6% of the patients (9/54) returned to sports in less than 6 weeks after surgery, 74% (40/54) returned to sports between 6 and 12 weeks after surgery, and 9.2% (5/ 54) returned to sports after 12 weeks (Figure 3). Of the 53 patients who returned to sports, 50 (94%) were able to return to the same level they had previous to the surgery. Three patients could not return to the same sport level (1 played recreational/noncollision sports and 2 played competitive/collision sports) because although they had good functional scores, they did not feel psychologically confident and/or because they feared they would suffer the same injury again. As shown in Table 2, the final functional outcomes were not related neither to the type of sports nor to the level of competition before surgery. Complications were found in 9 cases (16.6%) (Table 3). Three of these complications were considered as major (5.5%). The most serious consisted in a subclavian vein extrinsic compression and required osteosynthesis removal.
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TABLE 2 Results of Time to Return-to-Sport and Functional Scores by Type of Sport and Athletic Levela n Type of sport G1 (noncollision/nonoverhead) G2 (high-impact/collision sport) G3 (overhead sport) G4 (martial arts sport) Athletic level at time of injury Competitive Recreational
Time to Return, d
19 26 7 2
64 68 70 71
(5-180) (40-125) (25-131) (67-75)
31 23
68 (5-180) 71 (38-131)
QuickDASH Score
0.5 0.3 0.6 0.23
(0-2.2) (0-7.1) (0-4.6) (0-0.4)
0.23 (0-7.2) 0.44 (0-4.6)
Constant Score
95 94 96 91
(92-97) (92-98) (78-100) (86- 95)
95 (92-100) 91 (77-100)
a
Data are presented as mean (range).
TABLE 3 Summary of Complications Complication
n (%)
Major Nonunion Hardware loosening Subclavian vein compression Minor Hardware removal
3 1 1 1 6 5
(5.5) (1.8) (1.8) (1.8) (11.1) (9.3)
Hypertrophic scar Total
1 (1.8) 9 (16.6)
Athletic Level
Recreational Competitive Competitive 3 competitive, 2 recreational Recreational
Another patient suffered loss of reduction of the fracture 1 month after surgery, followed by implant loosening. This patient was the only one in the complication group who returned to sports before medical indication. Osteosynthesis revision was prescribed. The third patient developed a nonunion and had to undergo reoperation 13 months after the first surgery. The original implant was removed, the nonunion decorticated, and an ORIF with bone grafting was performed. At final follow-up, the 3 patients were able to return to their previous sports and at the same level they were before the first surgery. Plate removal after fracture consolidation was performed in 5 patients (9.3%) at a mean of 27 months after surgery (range, 14-42 months). The removal cause was hardware prominence and discomfort in 4 cases and pain in 1 case. None of those patients suffered a refracture after 12 months from removal. The remaining complication was a hypertrophic scar.
DISCUSSION Although acute treatment of displaced midshaft clavicular fractures remains controversial because of the increasing recognition of suboptimal outcomes after nonoperative treatment, primary operative fixation has become increasingly popular in the past few years. Different recent meta-analyses of randomized control trials comparing surgical versus nonoperative treatment of displaced clavicular fractures have shown greater
prevalence of nonunion, symptomatic malunion, and poor functional outcomes after nonsurgical management.9,20,21 Although clinical advantages of plate fixation compared with nonsurgical treatment were published in many previous randomized controlled studies,2,9,19 there is a lack of evidence evaluating the subgroup of athletes. Our hypothesis that ORIF of displaced clavicular fractures in athletes was a safe and effective procedure resulting in a reliable and timely return-to-sport was confirmed in this study. We obtained satisfactory results in mean Constant scores (94.1), QuickDASH score (0.4), and VAS scale (0.29). Furthermore 90% of patients returned to sports before 12 weeks and 98% of fractures consolidated at final follow-up. These findings are significant because this injury usually affects young and active patients, making rapid return to function and early union a priority in the treatment. Verborgt et al18 analyzed the results of 39 semiprofessional athletes with a displaced middle-third clavicle fracture that were treated operatively using rigid plate fixation. Radiographic union was achieved in 90% of athletes after 12 weeks with favorable functional scores. However, a high complication rate was reported including 18% wound infections, 5% refractures, and 75% transient neurological complications. The authors concluded that rigid plate fixation of middle-third clavicle fractures gives good results in the semiprofessional athlete at the expense of a significant risk for complications. In our study only 1 of the 54 patients could not return to sports, however it is important to highlight that the cause was related to the associated lesions (knee pain after tibial plateau fracture) and not to poor functional outcomes related to the clavicle fracture. Thus, if we consider only patients without concomitant limitation due to a secondary injury, 100% of patients were able to return to sports in our series. Most of the patients (94%) who resumed sports were able to return to the same level they had previous to the surgery. Nevertheless, it is important to emphasize that the main reason that prevented patients to return to the same level was fear of re-injury. This is the reason why some patients choose to change sports or decrease the intensity of their practice despite having good functional scores and no pain. Time to return-to-sport was similar between patients who played contact sports and those who played
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noncollision sports (mean, 66 days [G1], 69 days [G2], 70 days [G3], and 71 days [G4]) and among the competitive and the recreational groups. Therefore, favorable results were independent of the type of sport and the athletic level previous to the injury. Consequently, we do not delay the return to play in cases of contact sports. We did not see higher complication rates in the subgroup of patients who did not follow the medical indication to return to sports (16.6%). However, we still maintain the same rehabilitation protocol, as we believe that we do not have sufficient evidence to allow athletes to return earlier to sport practice. Meisterling et al10 previously analyzed return to athletic activity after plate fixation of displaced midshaft clavicle fractures in 29 patients. In their retrospective series, 100% of patients returned to sports, 90% were able to return before 12 weeks, and all the patients were satisfied with their treatment. However, in this study postoperative radiographs demonstrating unions were not obtained in 37% of patients, whereas we had radiographic control in all patients. We also had a high rate of return-to-sport in athletes although the time to return-to-sport varied, as they reported. Jubel et al8 reported on 12 athletes treated with intramedullary nailing. The mean time to return to training was 5.9 days, and the mean resumption of competition was 16.8 days. They reported no complications. However, other studies reported a high incidence of complications associated with intramedullary nailing. Frigg et al4 reported the need for open reduction in 62% of patients treated with elastic nails, with 70% of patients experiencing complications. In addition to this, Golish et al,5 in a biomechanical study, showed that plate fixation provides a more rigid fixation compared with intramedullary nails and may provide a stronger construct for early rehabilitation protocols; this is the reason why we prefer to treat midshaft clavicle fractures with ORIF in athletes. In conclusion, precontoured locking plate fixation for athletes with displaced midshaft clavicle fractures was successful in terms of return to previous level of athletic activity, having excellent clinical results, and a relatively low rate of complications. Future prospective randomized clinical trials are needed to determinate which surgical treatment is superior. Scan the QR code with your smartphone to view the In-Depth podcast associated with this article or visit http://ajsm.sagepub.com/site//misc/Index/ Podcasts.xhtml.
REFERENCES 1. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am. 1998;80(6):841-852.
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2. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1-10. 3. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160-164. 4. Frigg A, Rillmann P, Perren T, Gerber M, Ryf C. Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications. Am J Sports Med. 2009;37(2):352-359. 5. Golish SR, Oliviero JA, Francke EI, Miller MD. A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation. J Orthop Surg Res. 2008;3:28. 6. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997;79(4):537-539. 7. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602-608. 8. Jubel A, Andemahr J, Bergmann H, Prokop A, Rehm KE. Elastic stable intramedullary nailing of midclavicular fractures in athletes. Br J Sports Med. 2003;37(6):480-483. 9. McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012;94(8):675-684. 10. Meisterling SW, Cain EL, Fleisig GS, Hartzell JL, Dugas JR. Return to athletic activity after plate fixation of displaced midshaft clavicle fractures. Am J Sports Med. 2013;41(11):2632-2636. 11. Mirzatolooei F. Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle. Acta Orthop Traumatol Turc. 2011;45(1):34-40. 12. Neer CS. Nonunion of the clavicle. J Am Med Assoc. 1960;172:10061011. 13. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11(5):452-456. 14. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998;80(3):476-484. 15. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res. 1968;58:29-42. 16. Schemitsch LA, Schemitsch EH, Veillette C, Zdero R, McKee MD. Function plateaus by one year in patients with surgically treated displaced midshaft clavicle fractures. Clin Orthop Relat Res. 2011;469(12):3351-3355. 17. Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br. 1988;70(3):461-464. 18. Verborgt O, Pittoors K, Van Glabbeek F, Declercq G, Nuyts R, Somville J. Plate fixation of middle-third fractures of the clavicle in the semi-professional athlete. Acta Orthop Belg. 2005;71(1):17-21. 19. Virtanen KJ, Remes V, Pajarinen J, Savolainen V, Bjo¨rkenheim J-M, Paavola M. Sling compared with plate osteosynthesis for treatment of displaced midshaft clavicular fractures: a randomized clinical trial. J Bone Joint Surg Am. 2012;94(17):1546-1553. 20. Xu C, Li X, Cui Z, Diao X, Yu B. Should displaced midshaft clavicular fractures be treated surgically? A meta-analysis based on current evidence. Eur J Orthop Surg Traumatol. 2013;23(6):621-629. 21. Xu J, Xu L, Xu W, Gu Y, Xu J. Operative versus nonoperative treatment in the management of midshaft clavicular fractures: a metaanalysis of randomized controlled trials. J Shoulder Elbow Surg. 2014;23(2):173-181.
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Return to Sports After Plate Fixation of Displaced Midshaft Clavicular Fractures in Athletes Maximiliano Ranalletta, Luciano A. Rossi, Nicolás S. Piuzzi, Agustin Bertona, Santiago L. Bongiovanni and Gaston Maignon Am J Sports Med 2015 43: 565 originally published online December 9, 2014 DOI: 10.1177/0363546514559913 The online version of this article can be found at: http://ajs.sagepub.com/content/43/3/565
Published by: http://www.sagepublications.com
On behalf of: American Orthopaedic Society for Sports Medicine
Additional services and information for The American Journal of Sports Medicine can be found at: Email Alerts: http://ajs.sagepub.com/cgi/alerts Subscriptions: http://ajs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
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In-Depth
Return to Sports After Plate Fixation of Displaced Midshaft Clavicular Fractures in Athletes Maximiliano Ranalletta,* MD, Luciano A. Rossi,*y MD, Nicola´s S. Piuzzi,* MD, Agustin Bertona,* MD, Santiago L. Bongiovanni,* MD, and Gaston Maignon,* MD Investigation performed at the Italian Hospital of Buenos Aires, Buenos Aires, Argentina Background: Recent prospective randomized trials support primary plate fixation of displaced midshaft clavicle fractures. However, the safety and efficacy of this practice have not been well documented in athletes, nor has the time to return-to-sport. Purpose: To analyze the time to return-to-sport, functional outcomes, and complications in a group of athletes with displaced midshaft clavicle fractures treated using precontoured locking plates. Study Design: Case series; Level of evidence, 4. Methods: A total of 54 athletes with displaced midshaft clavicle fractures were treated with plate fixation between November 1, 2008, and December 31, 2012. The mean follow-up time was 22.4 months. Patients completed a questionnaire focused on the time to return-to-sport and treatment course. Functional outcomes were assessed with the Constant score and short version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Pain was evaluated with the visual analog scale (VAS). Radiographs were reviewed to identify radiographic union time, malunion, and nonunion. Results: Of the 54 patients, 53 returned to sports after open reduction and internal fixation of their fracture; 94% returned to the same level. The mean time to return-to-sport was 68 days (range, 5-180 days). Nine (16.6%) of the cases returned to sports before 6 weeks after surgery, 40 (74%) returned between 6 and 12 weeks, and 5 patients (9.2%) returned 12 weeks after surgery. The mean Constant score was 94.1 6 5.2 (range, 78-100), and the mean QuickDASH score was 0.4 6 4.7 (range, 0-7.1). The mean VAS pain score during follow-up was 0.29 6 1.0 (range, 0-5). Three major complications occurred: 1 extrinsic compression of the subclavian vein, 1 nonunion, and 1 hardware loosening. Hardware removal was necessary in 5 patients (9.3%). Conclusion: Plate fixation of displaced clavicle fractures in athletes is a safe procedure resulting in excellent functional outcomes, with an early return to the same level of sports in the majority of patients. Keywords: athletes; clavicular fractures; plate fixation
Clavicle fractures are common injuries and account for approximately 2.6% to 5% of all fractures in adults.13,14 Middle-third fractures are the most common type (80%). The latter are displaced in 48% of cases and comminuted in 19%.13,14 The most common mechanism for a clavicular fracture is a fall onto the ipsilateral shoulder, making athletes particularly prone to this injury.17 Traditionally, nonsurgical management has been favored as the treatment for most clavicular fractures.12,15 However,
recent evidence has emerged indicating that operative fixation presents lower nonunion rates, better functional outcomes, improved cosmesis, and greater patient satisfaction compared with closed treatment.2 Hill et al6 reported the results of 52 patients with completely displaced midshaft clavicular fractures treated nonoperatively and showed a 15% incidence of nonunion and 31% unsatisfactory results. Several recent prospective randomized clinical trials that compared nonoperative treatment with open reduction and internal fixation (ORIF) with plate fixation showed that operative treatment improved functional outcomes and significantly decreased the incidence of longterm complications such as nonunion and symptomatic malunion.2,11,16,19 Consequently, there has been a trend in the past few years to increase operative treatment. As this injury usually affects young, active patients, the treatment objective is to obtain early union and subsequently a rapid return to prior function. Favorable results with surgical treatment for middle-third clavicular fractures have been reported,9,11,19 however there is a lack of published literature referring to clinical outcomes in
y Address correspondence to Luciano A. Rossi, MD, Institute of Orthopedics ‘‘Carlos E. Ottolenghi,’’ Italian Hospital of Buenos Aires, Potosi 4247, CIP: 1199 Buenos Aires, Argentina (e-mail: luciano.rossi@ hospitalitaliano.org.ar). *Institute of Orthopedics ‘‘Carlos E. Ottolenghi,’’ Italian Hospital of Buenos Aires, Buenos Aires, Argentina. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 43, No. 3 DOI: 10.1177/0363546514559913 Ó 2014 The Author(s)
565 Downloaded from ajs.sagepub.com at Harvard Libraries on June 26, 2015
566
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The American Journal of Sports Medicine
TABLE 1 Demographic and Fracture-Related Characteristicsa Variable Sex Male Female Age, y, mean 6 SD Dominant arm No Yes Edinburgh classification Subtype B1 Subtype B2 Mechanism of injury Sports Motorcycle Fall Car accident Bicycle Other Pre-injury sport level Competitive Recreational
47 (87) 7 (13) 30.1 6 10.8 23 (43) 31 (57) 38 (70) 16 (30) 25 12 6 5 4 2
(46) (22) (11) (9) (7) (4)
29 (54) 25 (46)
a
Data are presented as n (%) unless otherwise indicated.
athletes with this injury and the ideal time required to return to sport.10,18 It has become our usual practice to perform ORIF of displaced midshaft clavicular fractures in athletes. We hypothesized that ORIF of displaced clavicular fractures in athletes is a safe and effective procedure, resulting in a reliable and timely return to play. The aim of this study was to analyze the time to return-to-sport, functional outcome, and complications of a group of athletes with displaced midshaft clavicular fractures treated using precontoured locking plates.
MATERIALS AND METHODS Between November 1, 2008, and December 31, 2012, we performed ORIF of displaced midshaft clavicular fractures on 54 clavicular fractures in 54 athletes. In all cases, internal fixation by precontoured plates (Acumed) with angular stability was used. Inclusion criteria were as follows: patients with closed type 2B fractures according to Edinburgh classification, timeframe within 3 weeks from injury, and age between 16 and 60 years. Patients were required to have an intention to return to sports postoperatively. Indications for ORIF were displaced or comminuted clavicular fracture. The ethics committee of the Italian Hospital of Buenos Aires approved this study (IRB: 00003580). Patient demographic and fracture characteristics are listed in Table 1. During the surgical procedure, patients received combined anesthesia (regional blockade 1 general anesthesia) and were placed in the beach-chair position with a pad behind the ipsilateral scapula. An anteroinferior approach centered in the fracture site was chosen in all cases. Once
Figure 1. One-month postoperative radiographs (45° uptilted anteroposterior). Open reduction and internal fixation with a 7-hole precontoured locking plate using 6 screws, 3 lateral and 3 medial, to focus. The patient started training 3 weeks after fracture and returned to competition 6 weeks after fracture. anatomic fracture reduction was achieved, we proceeded with internal fixation. The plate was placed on the clavicle superior side (Figure 1). In the presence of a third fragment we chose to place 1 or more interfragmentary screws. Plates with different number of holes and different amount of screws were used, with a minimum of 3 bicortical screws on each side of the fracture (Figure 1). After plating was completed, routine layered closure was accomplished. Once the procedure was over, radiological control was made at the operating room. Patients were discharged the same day or the day following surgery. Postoperative rehabilitation protocol consisted of arm sling during the first 2 postoperative weeks, with sling removal 4 times a day to perform pendulum exercises. Patients were not allowed to elevate the surgical arm above 90° in any plane during the first 3 weeks and were told to avoid lifting heavy weights for the first 6 weeks. After week 8, full shoulder active range of motion in all planes was allowed, with increase in intensity of strength and functional training for gradual return to activities and sports. Although clear instructions were given, we often observed that patients did not follow them. Clinical and radiological evaluation was performed during follow-up the first month weekly and then monthly until fracture consolidation was reached. Radiological evaluation consisted of frontal clavicle radiograph and a 45° up-tilted anteroposterior radiograph (Figure 2). Fracture consolidation was evaluated through clinical examination and through radiological analysis (looking for at least 3 consolidated corticals in 2 incidences). Functional outcome was evaluated using the Constant score3 and the short version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score.7 Residual pain was tested using the visual analog scale (VAS), with 0 indicating no pain and 10 maximum pain. All surgeryrelated complications and reoperations were documented. Patients were also asked if they had been able to practice their previous sports and if they had been able to perform them at the same level they had before the fracture.
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Figure 2. A 22-year-old male patient with football trauma. He had an Edinburgh type 2B-1 (simple, displaced) fracture. Patient sport level was divided into competitive sport (regular sport with competition and practice .2 times per week) and recreational sport (regular sport without competition \2 times per week). The distinctive types of shoulder-dependent sport were subdivided in an analog manner according to Allain et al1: noncollision/nonoverhead shoulder sport (G1), high-impact/collision sport (G2), overhead sport (G3), and martial arts sport (G4). Patients were allowed to return to sports when radiographic and clinical fracture union had occurred, full shoulder range of motion had been achieved, and shoulder strength was near 100%. When plate removal was required, we only restricted sports practice for 4 to 6 weeks in patients who practiced high-impact/collision sports (G2) to allow bone growth in the screw holes.
Statistical Methodology Continuous variables are presented as mean 6 SD, whereas categorical variables are given as absolute and relative frequencies. Statistical analysis was performed using the software STATA version 12 (Stata Corp).
RESULTS No patient was lost for follow-up, thus the analysis was made up of 54 fractures in 54 patients (Table 1); 47 patients were male (87%) and 7 (13%) were female, with a mean age of 30.1 6 10.8 years. There were 29 fractures on the left side and 25 on the right side; 31 (57%) were on the dominant side. All fractures were classified to group 2B according to the Edinburgh classification; specifically, 38 subtype B1 and 16 subtype B2 fractures were identified. None of these were open fractures, nor were they accompanied by neurovascular lesions at the time of surgery. The main cause of fracture was sport-related trauma (25 cases; 46%) with motorcycle-related accidents being the second most common cause (12; 22%) (Table 1). No patient was admitted to the intensive care unit. Five patients had associated lesions (1 tibial plateau fracture, 1 ankle fracture, 1
Figure 3. Percentage of patients who returned to sports after surgery. costal fracture, 1 midshaft humeral fracture, and 1 distal radius fracture), however none of them had a life-threatening condition. The mean elapsed time between fracture and surgery was 6.9 6 3.0 days (range, 2-12 days). The mean surgery time was 74.2 minutes (range, 43-117 min). There were no intraoperative complications. Mean follow-up was 22.4 6 19.6 months (range, 14-49 months). Fifty-three (98.1%) fractures consolidated. The mean Constant score was 94.1 6 5.2 (range, 78-100), the mean QuickDASH score was 0.4 6 4.7 (range, 0-7.1), and the mean VAS pain score was 0.29 6 1.0 (range, 0-5) at final follow-up. Of the 54 patients, 53 (98.1%) were able to return to sports. The patient who did not manage to return to sports had a concomitant tibial plateau fracture and attributed inability to resume sports to knee pain. The mean time to return to play was 68 days (10 weeks), with a range of 5 to 180 days; 16.6% of the patients (9/54) returned to sports in less than 6 weeks after surgery, 74% (40/54) returned to sports between 6 and 12 weeks after surgery, and 9.2% (5/ 54) returned to sports after 12 weeks (Figure 3). Of the 53 patients who returned to sports, 50 (94%) were able to return to the same level they had previous to the surgery. Three patients could not return to the same sport level (1 played recreational/noncollision sports and 2 played competitive/collision sports) because although they had good functional scores, they did not feel psychologically confident and/or because they feared they would suffer the same injury again. As shown in Table 2, the final functional outcomes were not related neither to the type of sports nor to the level of competition before surgery. Complications were found in 9 cases (16.6%) (Table 3). Three of these complications were considered as major (5.5%). The most serious consisted in a subclavian vein extrinsic compression and required osteosynthesis removal.
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TABLE 2 Results of Time to Return-to-Sport and Functional Scores by Type of Sport and Athletic Levela n Type of sport G1 (noncollision/nonoverhead) G2 (high-impact/collision sport) G3 (overhead sport) G4 (martial arts sport) Athletic level at time of injury Competitive Recreational
Time to Return, d
19 26 7 2
64 68 70 71
(5-180) (40-125) (25-131) (67-75)
31 23
68 (5-180) 71 (38-131)
QuickDASH Score
0.5 0.3 0.6 0.23
(0-2.2) (0-7.1) (0-4.6) (0-0.4)
0.23 (0-7.2) 0.44 (0-4.6)
Constant Score
95 94 96 91
(92-97) (92-98) (78-100) (86- 95)
95 (92-100) 91 (77-100)
a
Data are presented as mean (range).
TABLE 3 Summary of Complications Complication
n (%)
Major Nonunion Hardware loosening Subclavian vein compression Minor Hardware removal
3 1 1 1 6 5
(5.5) (1.8) (1.8) (1.8) (11.1) (9.3)
Hypertrophic scar Total
1 (1.8) 9 (16.6)
Athletic Level
Recreational Competitive Competitive 3 competitive, 2 recreational Recreational
Another patient suffered loss of reduction of the fracture 1 month after surgery, followed by implant loosening. This patient was the only one in the complication group who returned to sports before medical indication. Osteosynthesis revision was prescribed. The third patient developed a nonunion and had to undergo reoperation 13 months after the first surgery. The original implant was removed, the nonunion decorticated, and an ORIF with bone grafting was performed. At final follow-up, the 3 patients were able to return to their previous sports and at the same level they were before the first surgery. Plate removal after fracture consolidation was performed in 5 patients (9.3%) at a mean of 27 months after surgery (range, 14-42 months). The removal cause was hardware prominence and discomfort in 4 cases and pain in 1 case. None of those patients suffered a refracture after 12 months from removal. The remaining complication was a hypertrophic scar.
DISCUSSION Although acute treatment of displaced midshaft clavicular fractures remains controversial because of the increasing recognition of suboptimal outcomes after nonoperative treatment, primary operative fixation has become increasingly popular in the past few years. Different recent meta-analyses of randomized control trials comparing surgical versus nonoperative treatment of displaced clavicular fractures have shown greater
prevalence of nonunion, symptomatic malunion, and poor functional outcomes after nonsurgical management.9,20,21 Although clinical advantages of plate fixation compared with nonsurgical treatment were published in many previous randomized controlled studies,2,9,19 there is a lack of evidence evaluating the subgroup of athletes. Our hypothesis that ORIF of displaced clavicular fractures in athletes was a safe and effective procedure resulting in a reliable and timely return-to-sport was confirmed in this study. We obtained satisfactory results in mean Constant scores (94.1), QuickDASH score (0.4), and VAS scale (0.29). Furthermore 90% of patients returned to sports before 12 weeks and 98% of fractures consolidated at final follow-up. These findings are significant because this injury usually affects young and active patients, making rapid return to function and early union a priority in the treatment. Verborgt et al18 analyzed the results of 39 semiprofessional athletes with a displaced middle-third clavicle fracture that were treated operatively using rigid plate fixation. Radiographic union was achieved in 90% of athletes after 12 weeks with favorable functional scores. However, a high complication rate was reported including 18% wound infections, 5% refractures, and 75% transient neurological complications. The authors concluded that rigid plate fixation of middle-third clavicle fractures gives good results in the semiprofessional athlete at the expense of a significant risk for complications. In our study only 1 of the 54 patients could not return to sports, however it is important to highlight that the cause was related to the associated lesions (knee pain after tibial plateau fracture) and not to poor functional outcomes related to the clavicle fracture. Thus, if we consider only patients without concomitant limitation due to a secondary injury, 100% of patients were able to return to sports in our series. Most of the patients (94%) who resumed sports were able to return to the same level they had previous to the surgery. Nevertheless, it is important to emphasize that the main reason that prevented patients to return to the same level was fear of re-injury. This is the reason why some patients choose to change sports or decrease the intensity of their practice despite having good functional scores and no pain. Time to return-to-sport was similar between patients who played contact sports and those who played
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Return to Sports After Plate Fixation in Clavicular Fracture
noncollision sports (mean, 66 days [G1], 69 days [G2], 70 days [G3], and 71 days [G4]) and among the competitive and the recreational groups. Therefore, favorable results were independent of the type of sport and the athletic level previous to the injury. Consequently, we do not delay the return to play in cases of contact sports. We did not see higher complication rates in the subgroup of patients who did not follow the medical indication to return to sports (16.6%). However, we still maintain the same rehabilitation protocol, as we believe that we do not have sufficient evidence to allow athletes to return earlier to sport practice. Meisterling et al10 previously analyzed return to athletic activity after plate fixation of displaced midshaft clavicle fractures in 29 patients. In their retrospective series, 100% of patients returned to sports, 90% were able to return before 12 weeks, and all the patients were satisfied with their treatment. However, in this study postoperative radiographs demonstrating unions were not obtained in 37% of patients, whereas we had radiographic control in all patients. We also had a high rate of return-to-sport in athletes although the time to return-to-sport varied, as they reported. Jubel et al8 reported on 12 athletes treated with intramedullary nailing. The mean time to return to training was 5.9 days, and the mean resumption of competition was 16.8 days. They reported no complications. However, other studies reported a high incidence of complications associated with intramedullary nailing. Frigg et al4 reported the need for open reduction in 62% of patients treated with elastic nails, with 70% of patients experiencing complications. In addition to this, Golish et al,5 in a biomechanical study, showed that plate fixation provides a more rigid fixation compared with intramedullary nails and may provide a stronger construct for early rehabilitation protocols; this is the reason why we prefer to treat midshaft clavicle fractures with ORIF in athletes. In conclusion, precontoured locking plate fixation for athletes with displaced midshaft clavicle fractures was successful in terms of return to previous level of athletic activity, having excellent clinical results, and a relatively low rate of complications. Future prospective randomized clinical trials are needed to determinate which surgical treatment is superior. Scan the QR code with your smartphone to view the In-Depth podcast associated with this article or visit http://ajsm.sagepub.com/site//misc/Index/ Podcasts.xhtml.
REFERENCES 1. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am. 1998;80(6):841-852.
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2. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1-10. 3. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160-164. 4. Frigg A, Rillmann P, Perren T, Gerber M, Ryf C. Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications. Am J Sports Med. 2009;37(2):352-359. 5. Golish SR, Oliviero JA, Francke EI, Miller MD. A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation. J Orthop Surg Res. 2008;3:28. 6. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997;79(4):537-539. 7. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602-608. 8. Jubel A, Andemahr J, Bergmann H, Prokop A, Rehm KE. Elastic stable intramedullary nailing of midclavicular fractures in athletes. Br J Sports Med. 2003;37(6):480-483. 9. McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012;94(8):675-684. 10. Meisterling SW, Cain EL, Fleisig GS, Hartzell JL, Dugas JR. Return to athletic activity after plate fixation of displaced midshaft clavicle fractures. Am J Sports Med. 2013;41(11):2632-2636. 11. Mirzatolooei F. Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle. Acta Orthop Traumatol Turc. 2011;45(1):34-40. 12. Neer CS. Nonunion of the clavicle. J Am Med Assoc. 1960;172:10061011. 13. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11(5):452-456. 14. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998;80(3):476-484. 15. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res. 1968;58:29-42. 16. Schemitsch LA, Schemitsch EH, Veillette C, Zdero R, McKee MD. Function plateaus by one year in patients with surgically treated displaced midshaft clavicle fractures. Clin Orthop Relat Res. 2011;469(12):3351-3355. 17. Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br. 1988;70(3):461-464. 18. Verborgt O, Pittoors K, Van Glabbeek F, Declercq G, Nuyts R, Somville J. Plate fixation of middle-third fractures of the clavicle in the semi-professional athlete. Acta Orthop Belg. 2005;71(1):17-21. 19. Virtanen KJ, Remes V, Pajarinen J, Savolainen V, Bjo¨rkenheim J-M, Paavola M. Sling compared with plate osteosynthesis for treatment of displaced midshaft clavicular fractures: a randomized clinical trial. J Bone Joint Surg Am. 2012;94(17):1546-1553. 20. Xu C, Li X, Cui Z, Diao X, Yu B. Should displaced midshaft clavicular fractures be treated surgically? A meta-analysis based on current evidence. Eur J Orthop Surg Traumatol. 2013;23(6):621-629. 21. Xu J, Xu L, Xu W, Gu Y, Xu J. Operative versus nonoperative treatment in the management of midshaft clavicular fractures: a metaanalysis of randomized controlled trials. J Shoulder Elbow Surg. 2014;23(2):173-181.
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