Tsai Tsung-Ying, Hsu Shan-Ling, Hsu Chi-Hsiang, Liao Chin-Yi, Lu Yu-Der
The Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan.
Arch Orthop Trauma Surg. 2025 Jan 7;145(1):111. doi: 10.1007/s00402-024-05731-6.
The optimal management strategy for unstable distal clavicular fractures remains controversial. Recent studies on plate techniques have reported good-to-excellent outcomes with no serious complications. The questions are that: (1) Does the use of wire augmentation with locking plate in distal part (distal wire augmentation) reduce radiographic loss of reduction (RLOR) and get earlier bony union in distal clavicular fractures? (2) Which fixation methods are associated with a higher incidence of acromioclavicular (AC) joints arthritis or subluxation? We collected and analyzed clinical studies on different plate fixation methods for unstable fractures to identify the best surgical modality.
This retrospective case-control study included 101 patients with Neer types IIB and V unstable distal clavicle fractures treated using plate techniques. The patients were divided into four groups according to the surgical procedure: hook plate (HP group) (n = 13), lateral locking plate alone (LP group) (n = 41), locking plate with coracoclavicular (CC) ligament suture repair (LPC group) (n = 26), and locking plate with distal wire augmentation (LPA group) without CC repair (n = 21). The clinical outcomes of shoulder function were the mean Constant score and the University of California-Los Angeles (UCLA) shoulder scale. The bony union time, loss of CC distance reduction, and AC joint condition were used to evaluate the radiographic results. One-way ANOVA, Kruskal-Wallis test, and chi-square test were performed to compare differences between groups. Multiple p-value comparison corrections were calculated using the Bonferroni method.
There were no significant differences in the mean Constant and UCLA scores among the groups after 1 year of follow-up. All fractures healed. The LPA and HP groups achieved earlier bone union (LPA 8.4 weeks, HP 8.9 weeks, LP 12.6 weeks, and LPC 13.4 weeks, P = 0.000); however, the HP group had the highest complication rate and required bone removal (LPA 4.0%, HP 23.1%, LP 0.0%, LPC 0.0%, P = 0.003). A low rate of RLOR was observed in the LPA group (LPA 9.5%, HP 23.1%, LP 22.0%, LPC 30.8%, P = 0.362). The incidence of AC joint subluxation was higher in the Neer type V group and was unrelated to surgical methods.
Hook plate and locking plate with distal wire augmentation in distal clavicle fractures result in an earlier time to bone union when compared with CC suture repair or non-CC suture repair techniques. However, HP may have the higher complication rate and require subsequent implant removal. The incorporation of distal wire augmentation appears to be beneficial in maintaining fracture reduction. In the future, larger prospective studies are needed to confirm these findings.
Level III, therapeutic study.
不稳定型锁骨远端骨折的最佳治疗策略仍存在争议。近期有关钢板技术的研究报告了良好至优异的治疗效果，且无严重并发症。问题在于：（1）在锁骨远端使用带钢丝增强的锁定钢板（远端钢丝增强）是否能减少影像学上的复位丢失（RLOR）并使锁骨远端骨折更早实现骨愈合？（2）哪种固定方法与肩锁关节（AC）关节炎或半脱位的发生率较高相关？我们收集并分析了关于不稳定骨折不同钢板固定方法的临床研究，以确定最佳手术方式。
这项回顾性病例对照研究纳入了101例采用钢板技术治疗的Neer IIB型和V型不稳定锁骨远端骨折患者。根据手术方式将患者分为四组：钩钢板组（HP组）（n = 13）、单纯外侧锁定钢板组（LP组）（n = 41）、带喙锁韧带缝合修复的锁定钢板组（LPC组）（n = 26）以及不带喙锁修复的带远端钢丝增强的锁定钢板组（LPA组）（n = 21）。肩部功能的临床结局采用平均Constant评分和加州大学洛杉矶分校（UCLA）肩部评分量表。采用骨愈合时间、喙锁距离复位丢失情况以及肩锁关节状况来评估影像学结果。进行单因素方差分析、Kruskal - Wallis检验和卡方检验以比较组间差异。使用Bonferroni方法计算多个p值比较校正值。
随访1年后，各组间平均Constant评分和UCLA评分无显著差异。所有骨折均愈合。LPA组和HP组实现骨愈合的时间更早（LPA组8.4周，HP组8.9周，LP组12.6周，LPC组13.4周，P = 0.000）；然而，HP组的并发症发生率最高且需要取出内固定物（LPA组4.0%，HP组23.1%，LP组0.0%，LPC组0.0%，P = 0.003）。LPA组的RLOR发生率较低（LPA组9.5%，HP组23.1%，LP组22.0%，LPC组30.8%，P = 0.362）。Neer V型组肩锁关节半脱位的发生率较高，且与手术方法无关。
与喙锁韧带缝合修复或非喙锁韧带缝合修复技术相比，锁骨远端骨折使用钩钢板和带远端钢丝增强的锁定钢板可使骨愈合时间更早。然而，HP组可能并发症发生率更高且需要后续取出内固定物。采用远端钢丝增强似乎有利于维持骨折复位。未来，需要更大规模的前瞻性研究来证实这些发现。
III级，治疗性研究。
