Does anteroinferior fixation of midshaft clavicle fractures have a lower rate of hardware removal and complications? A multicenter retrospective study [poster]
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Background/Purpose: Recent publications suggest that surgical management of displaced midshaft clavicle fractures may result in improved patient outcomes relative to nonoperative management. Like all interventions, however, this procedure carries known risks. One risk is hardware-related symptoms requiring a secondary surgical procedure. While the rate of hardware removal (HWR) varies, it has been reported to be as high as 50% in some series. As a result, there has been considerable interest in developing new approaches to decrease this morbidity. One technique described is anteroinferior plating of clavicles. In addition to offering a safe trajectory of screw placement, anteroinferior plate placement is thought to reduce plate prominence, which could potentially reduce the rate of hardware removal. The primary objective of this study was to compare HWR rates with plates positioned superiorly to those positioned anteroinferiorly. Secondary objectives were to report any significant correlation between HWR, complications demographics, fracture characteristics, or implant types and superior versus anteroinferior plating. Methods: A retrospective study of 328 consecutive midshaft (15.B1, B2, B3) clavicle fractures treated by open reduction and internal fixation at three Level I trauma centers between 2006 and 2010 was performed. All distal (15.C) and proximal (15.A) fractures were excluded. In addition, any midshaft fractures in which dual plate fixation was utilized were excluded. Electronic medical records and radiographic studies were reviewed to collect patient demographics, injury characteristics, operative techniques, and outcomes. Results: Of the 328 fractures, the rates of hardware failure, nonunion, and infection were 2.7%, 1.5%, and 0.9%, respectively. Plate location, type, and size did not have an affect on nonunion or infection rate; however, there was a higher rate of hardware failure in patients with 2.7-mm plates compared to 3.5-mm (4.7% vs 1.1%). This difference demonstrated a statistical trend (P = 0.08). HWR was performed on 42 of 328 patients (12.8%). Reasons for removal included symptomatic hardware (76%), nonunion (9.5%), hardware failure (4.7%), cultural preference (4.7%), and infection (2.3%). Analysis comparing patients requiring HWR to those not requiring revealed both females and fractures classified as 15.B1 had a statistically higher rate of HWR (P <0.001 and P<0.05, respectively). There was no statistical difference for age, body mass index, or tobacco use. 205 fractures (62.5%) were plated anteroinferiorly and 123 (37.5%) superiorly. Comparative analysis of anteroinferior plating and superior plating showed that HWR rates were not statistically significantly different than the anteroinferior group (14.1% vs 10.7%). Conclusion: This study does not provide compelling evidence that either plate location is superior in terms of reducing rates of HWR or complications. Surgeon experience should guide operative decision making, balancing the mechanical and biologic solution for each individual fracture.