John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, Texas.
Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas.
JBJS Rev. 2023 Jan 24;11(1). doi: e22.00171. eCollection 2023 Jan 1.
Surgical repair of clavicle fractures is being employed more frequently, although most fractures are still treated conservatively. Both can result in nonunion. Current treatments for clavicle nonunion include open reduction with internal fixation (ORIF) plating without bone graft, ORIF plating with bone graft, and intramedullary pin fixation.
We performed a systematic review and meta-analysis of studies reporting outcome, complication, and reoperation rates following surgical treatment for clavicle nonunion. Subgroup analysis was undertaken for outcome and complication rates between single plating and intramedullary pin fixation, bone graft use, and nonunion time length definition.
Fifty-three studies met inclusion criteria (1,258 clavicle nonunions). Mean clinical follow-up was 2.6 years. Seventy-two percent of nonunions were of the middle third, 1% were proximal third, 12% were distal third, and 15% were not reported. Forty-eight percent of nonunions were atrophic or oligotrophic and 17% were hypertrophic (35% not reported). Mean time to union was 13.6 weeks. Ninety-five percent of patients achieved union after the primary nonunion surgery. Overall complication rate was 17%. Single-plating fixation had significantly faster union time (15.2 vs. 19.8 weeks), lower reoperation rate (23% vs. 37%), and hardware removal rate (20% vs. 34%) than intramedullary pin fixation. Bone graft had significantly lower rates of delayed union (0.6% vs. 3.6%) but higher complication (15% vs. 8%) and reoperation rates (29% vs. 14%) than the other groups. Studies that defined nonunion after 3 months had significantly faster union times than the 6-month studies (13 vs. 16 weeks). The 3-month group had a significantly lower overall complication rate (12% vs. 25%) and hardware/fixation failure rate (3% vs. 5.5%) than the 6-month group.
This systematic review is the largest report of complications, reoperations, and patient outcomes of clavicle nonunions after surgical intervention in the current literature. Plating showed faster time to union and lower reoperation rates than intramedullary pin fixation. Bone graft use showed lower rates of delayed union but substantially higher rates of complications and reoperations. Reports with a definition of nonunion at 3 months showed faster union times and lower complication rates compared to reports with a definition of nonunion that was 6 months or greater. Surgery could be considered at 3 months post-injury in cases of symptomatic non-united clavicle fracture, and plating results in reliable outcomes. Adjuvant bone grafting requires further study to determine its value and risk/benefit ratio.
Level IV, Systematic Review. See Instructions for Authors for a complete description of levels of evidence.
锁骨骨折的手术修复越来越普遍，尽管大多数骨折仍采用保守治疗。这两种方法都可能导致不愈合。锁骨不愈合的当前治疗方法包括切开复位内固定（ORIF）钢板无植骨、ORIF 钢板植骨和髓内针固定。
我们对报告手术治疗锁骨不愈合的结果、并发症和再手术率的研究进行了系统评价和荟萃分析。在单钢板和髓内针固定、植骨使用和不愈合时间定义之间进行了亚组分析，以评估结果和并发症发生率。
53 项研究符合纳入标准（1258 例锁骨不愈合）。平均临床随访时间为 2.6 年。72%的不愈合位于中段，1%位于近段，12%位于远段，15%未报告。48%的不愈合为萎缩性或少细胞性，17%为肥大性（35%未报告）。平均愈合时间为 13.6 周。95%的患者在初次非愈合手术后达到愈合。总体并发症发生率为 17%。单钢板固定的愈合时间明显更快（15.2 周 vs. 19.8 周），再手术率（23% vs. 37%）和内固定去除率（20% vs. 34%）均低于髓内针固定。植骨的延迟愈合率明显较低（0.6% vs. 3.6%），但并发症（15% vs. 8%）和再手术率（29% vs. 14%）较高。将非愈合定义为 3 个月后，与 6 个月的研究相比，愈合时间明显缩短（13 周 vs. 16 周）。3 个月组的总体并发症发生率（12% vs. 25%）和内固定/固定失败率（3% vs. 5.5%）明显低于 6 个月组。
这是当前文献中关于锁骨不愈合后手术干预的并发症、再手术和患者结局的最大报告。钢板固定的愈合时间比髓内针固定更快，再手术率更低。植骨的延迟愈合率较低，但并发症和再手术率明显较高。将非愈合定义为 3 个月的报告与将非愈合定义为 6 个月或更长时间的报告相比，显示出更快的愈合时间和更低的并发症发生率。对于有症状的锁骨骨折，可考虑在受伤后 3 个月进行手术，如果使用钢板固定，可获得可靠的结果。辅助植骨需要进一步研究以确定其价值和风险/效益比。
IV 级，系统评价。有关证据水平的完整描述，请参见作者说明。
