Comments on the Article “Comparison of Locking Plate Osteosynthesis versus Coracoclavicular Stabilization for Neer Type IIB Lateral Clavicle Fractures”: To the Editor

To the Editor:

We read with interest the recent article, “Comparison of locking plate osteosynthesis versus coracoclavicular stabilization for Neer Type IIB lateral clavicle fractures,” by Kim et al.¹⁾ They compared outcomes and complications between pre-contoured locking plate osteosynthesis and coracoclavicular stabilization using a TightRope for the treatment of type IIB fractures. We really appreciate the work done by the authors. However, we would also like to point some of our concerns regarding the paper.

First, validity of coracoclavicular distance (CCD) measurement in this article was considerably limited, since CCDs were measured at rest on plain radiographs without weight loading. Erdle et al.²⁾ found that CCD differences remained increased by 34% compared to the healthy, contralateral side at 54.2-month follow-up between two internal fixation methods for the treatment of Neer type IIB lateral clavicle fractures. The CCD differences were expressed as percentage deviations of the affected relative to the healthy, contralateral side. Therefore, we recommend anterior–posterior stress radiographs with 10 kg vertical loading should be conducted bilaterally, and the vertical stability of the injured side could be compared to the healthy, contralateral side on the basis of virtually identical projections.

Second, suture button devices including the TightRope have been widely used in the treatment of acute acromioclavicular (AC) joint dislocation. The authors in this study obtained satisfactory radiologic and clinical outcomes with an acceptable complication rate after TightRope fixation for Neer type IIB fractures.¹⁾ Unlike the firm fixation of locking plate osteosynthesis, the TightRope device provides flexible coracoclavicular stabilization. The clavicular button frequently tends to migrate through the clavicle and may cause loss of reduction and bone fragment displacement. Therefore, in addition to the bone healing rate within 6 months after surgery, we also want to know whether the bone healing time was different between the two groups.

Third, osteoarthritis of the AC joint is a common complication after surgery.²,³⁾ Patients may achieve significantly inferior clinical outcome scores due to posttraumatic AC joint arthrosis. However, the AC joint-specific functional outcome score such as Taft score should be applied.²⁾

Furthermore, a few previous studies have reported arthroscopic treatments for distal clavicle fractures.⁴,⁵⁾ Arthroscopic techniques allowed for the diagnosis of any intra-articular glenohumeral injuries and their treatment, permitting a better evaluation of long-term outcomes based on associated pathologies. Therefore, we think the patients in the coracoclavicular stabilization group could be treated using an arthroscopic technique in the future to decease the rate of complications and obtain better functional outcome scores.