A simple surgical technique for correcting malunion after midshaft clavicle fracture

Abstract

Clavicle malunion occurs in two-thirds of all clavicle fractures treated conservatively. It can lead to pain, shoulder dysfunction and cosmetic complaints. Surgical treatment of all midshaft fractures will lead to overtreatment, as not all malunions are symptomatic. In the past, several treatment modalities for correcting malunion of the clavicle have been described, and all have been successful but none have shown superiority. This article describes a new surgical technique with excising a wedge to realign the clavicle malunion.

Introduction

The optimal treatment of clavicle malunion is a subject of ongoing debate in orthopedics. About two-thirds of all clavicle fractures treated non-operatively end up having some degree of malunion, with an average shortening of 1.2 cm.^1–3 The shortening occurs as a result of the medializing forces of the pectoralis, the trapezoid, and the latissimus dorsi muscles pulling the shoulder girdle medially.⁴ Not all malunions have an unfavorable outcome. A malunion of 1.4–2 cm is thought to have a higher chance of creating a symptomatic malunion.^1,2,5–8 Symptoms regarding the malunion can differ from pain, loss of strength, rapid fatigue of the shoulder up to cosmetic complaints.^2,6,9–11 These complaints can vary from mild to severe complaints in daily life. No conservative treatment modality has been reported regarding clavicle malunion.⁴ Several surgical techniques to correct the malunion have been described.

McKee et al. described a technique where a multi-plane osteotomy through the original fracture is performed.¹² Following the osteotomy, a reduction is performed. After reduction, a plate is placed to retain length and provide stability. These plates can be placed either postero-superior or antero-inferior to reduce the risks of complications.^13–16 Also intramedullary fixation has been described as a fixation option in both fracture treatment as well as with correction osteotomy.^17,18 Most authors describe a quite similar technique either with or without bone graft.^{11,12,17,19–23} All authors reported satisfying results following the malunion correction with improved function and fewer complaints. McKee also described a sliding osteotomy in case of severe remodeling. With this technique, the main focus is regaining length of the clavicle.¹²

Recently, the treatment of clavicle malunion has gained renewed attention with the introduction of computer-assisted 3D reconstructions.^24–27 Patient-specific osteotomy guides are created using CT images of both clavicles. With this technique, the contralateral clavicle is used as a reference to recreate the affected clavicle. In this way, not only the length is restored but also the alignment of the former fracture ends.

All of the abovementioned techniques have been reported successful, but none have shown superiority.²⁸ We have developed a technique based on the sliding osteotomy with excising a wedge for more anatomic correction of clavicle malunion without the necessity of CT and 3D reconstructions or difficult multi-plane osteotomy. Early results look promising.

Operative technique

Most, if not all, malunions of the midshaft will be with the medial end pulled superiorly and a little bit posterior and the lateral end pulled to inferior and a little anterior. Most of the deformity is in the coronal plane. Although the clavicle shortens with malunion, there is usually excessive bone formation due to the callus formation between the overriding ends of the fracture. That is why removing bone with correction will aid in reconstructing the anatomy. To plan a correction, in our institution, X-rays of the bilateral clavicle in two planes and one X-ray centered on the sternum showing both clavicles are obtained (Figure 1). The uninjured clavicle serves as a reference, although in normal situation, there can be differences between a right and left clavicle.²⁹ The radiologic as well as the clinical shortening is measured and documented because radiologic shortening usually underestimates the actual shortening.¹² In Figure 2, the planned osteotomy is showed. The planned osteotomy will be perpendicular to the plane in which the deformity exists, so it will be close to the transversal plane. The osteotomy is from superolateral oblique across the malunion to inferomedial.

Figure 1.

X-ray centered on the sternum showing both clavicles.

Figure 2.

Osteotomy and correction of the malunion.

The patients are placed in standard beach chair position. The affected clavicle is identified and draped free. Other than a standard superior approach, which can also be used for this procedure, an approach of the clavicle through a more vertical incision along the skin lines was used (incision with an angle about 30° with long axis of the clavicle, 60° with the horizontal plane, mimicking a sabre cut). The myofascial layer is exposed subcutaneously. The myofascial layer is opened along the clavicle. The malunion is identified and cleared of the soft tissue so that it can be visualized. Now the line of the osteotomy can be identified and marked by electrocautery. The osteotomy will be nearly perpendicular to the deformity and will most likely make an angle of around 60° to the horizontal plane. The more shortening has occurred, the longer the osteotomy can be made and hence more correction can and needs to be achieved. Now the osteotomy can be made. Once the ends are loose, the ends can be further released. If the clavicle is now lengthened sliding the ends to the measured and documented length and fixing them with a reduction clamp, we can see that length is corrected but an angle between the lateral and medial shaft remains. Now this angle is measured. The reduction clamp is taken out and rotation between the medial and the lateral ends is observed. If rotation is observed, this can be considered together with the shaft angle to determine the biplane angle of the wedge in the sagittal and coronal plane that needs to be removed. Now we remove a wedge from one of the ends matching that angle (Figure 2). Preferable is removing the wedge from the medial part, as this part is displaced the most after a midshaft clavicle fracture. After the wedge is removed, the clavicle is lengthened again and the osteotomy ends are pressed together. Malalignment in the transverse plane can now also be corrected (Figure 3). The lengthening can now be measured from the bare osteotomy surface of the lateral side that is exposed. Because of the wedge that is removed, some of this surface will already be exposed before lengthening. Therefore, this method slightly overestimates the lengthening. Most of the time, an anatomic clavicle plate will now fit over the clavicle or the plate can be adjusted a little. A void can be filled with bone from the removed wedge. Now a plate and screws can be applied with usually a lag screw through the plate, but this depends on the plane of the osteotomy and the type of plate. Closure of the myofascial layer, subcutaneous and intracutaneous stitches. Figure 4 shows the pre- and postop X-ray. The patients receive a simple sling for the first week. After that, patients can use the arm in daily activity but are advised to refrain from exerting strength on the shoulder for the first six weeks.

Figure 3.

Exposure of the clavicle. The parallel ends of the osteotomy after the wedge has been removed. The clavicle can now be lengthened and a plate can be applied.

Figure 4.

Situation before and after surgery.

Results

We have established five patients in the period 2013–2018 with symptomatic clavicle malunion after displaced midshaft clavicle fracture. All of the patients experienced pain in the shoulder girdle, experienced struggles in sporting activities (sports ranging from yoga to bicycle racing). One patient also had severe cosmetic complaints and another one experienced numbness and paresthesia. Patients had a mean radiographic shortening of 1.5 cm (range 0.9 cm–2.8 cm). The radiographic shortenings were measured using the opposite clavicle as a reference. In all patients, the orthopedic surgeon examined the clavicles and measured a shortening of at least 1 cm during physical examination. All surgeries were performed by the same orthopedic surgeon (RJH).

All but one patient were slightly under corrected (0.2 cm shortening remaining) when compared with the contralateral clavicle (Table 1). All patients had a bony union of the osteotomy within three months of the surgery. We did not have any complications in this group. Disabilities of the arm, shoulder and hand (DASH) scores at an average of 8.4 month (range 3 to 18) showed significant improvement. All patients were satisfied with the outcome and would undergo surgery again now knowing the outcome.

Table 1.

Results.

Patient	Side	DASH		Radiographic shortening		Plate removal
		Preop	Postop	Preop	Postop
1	Right	11	5	1.6 cm	0.0 cm	No
2	Right	41	5	0.9 cm	−0.4 cm	No
3	Left	29	2	0.9 cm	−0.2 cm	Yes
4	Left	22	8	2.8 cm	−0.1 cm	Yes
5	Left	27	9	1.3 cm	−0.2 cm	No

DASH: disabilities of the arm, shoulder and hand.

Discussion

In this surgical note, a new technique for the treatment of clavicle malunion is described. The symptomatic clavicle malunion has been described by many authors before.^{1,2,5,7,10,30,31} Several authors have described successful surgical techniques to treat these symptomatic malunions, but none have shown superiority.²⁸ This technique has been applied in five patients and early results look promising with on average over 20 points decrease of DASH score.

The surgical technique as described as above is an altered version of the sliding osteotomy technique described by McKee et al.¹² It is a relatively simple technique which requires plane X-rays, no additional equipment or scans. Therefore, it is an inexpensive technique. It does not reconstruct the clavicle as closely as an osteotomy through the original fracture plane. However, as midshaft clavicula fractures are extra articular fractures and the deformity in malunion is predictable, this simpler technique is for this purpose just as effective. It is also possible in case of severe remodeling where the original fracture is no longer recognizable.

The advantages of the 3D reconstructions technique in complex reconstructive surgical cases are clear, but in the case of clavicle malunion, it seems to be unnecessary complicated.

In conclusion, the surgical technique as described in this paper seems to be a good option in the treatment of clavicle malunion. The first results look promising and the technique does not require additional equipment or examination. Further comparative research between all techniques should be done to show which technique is superior.