treatment of unstable distal clavicle fractures using two suture anchors and suture tension bands

5
Treatment of unstable distal clavicle fractures using two suture anchors and suture tension bands Sang-Jin Shin *, Kwon Jae Roh, Jong Oh Kim, Hoon-Sang Sohn Department of Orthopaedic Surgery, Ewha Womans University, School of Medicine, 911-1, Mok-Dong, Yangcheon-Ku, 158-710 Seoul, Republic of Korea Surgical treatment is often recommended for the management of displaced fractures in the distal third of the clavicle caused by a high rate of nonunion following conservative treatment. 7,21 Edwards et al. 7 demonstrated a 30% rate of nonunion after non-operative management. Moreover, an additional healing period of greater than 6 weeks has been reported to be required for non-operative treatments. 23 These morbidities are attributable in part to fracture displacements caused by opposing forces acting on the fragments. The trapezius muscle, attached to the medial fragment, displaces the medial clavicle superiorly and the weight of the arm draws the lateral fragment inferiorly, which results in major displacement and nonunion. In addition, the severity of associated ligamentous disruption, especially of the coracoclavicular (CC) ligaments, also contributes to nonunion. 12 Distal clavicle fractures are also classified according to the injuries of CC ligaments because the conoid and trapezoid ligaments are important structures for the fracture- healing process. 20 Biomechanical investigations have confirmed that the CC ligaments primarily restrain vertical translation. 6,10 Furthermore, if CC ligament disruptions are left untreated, the fracture fragments may be unstable and the risk of nonunion increased. Therefore, the surgical treatment for distal clavicle fracture should be considered to include reconstruction of disrupted CC ligaments to stabilise the clavicle from superior migration and to provide an environment conducive with fracture union. Although numerous surgical methods have been proposed, no consensus has been reached yet regarding the optimal surgical treatment for displaced distal clavicle fractures. Various fixation techniques have been used, including wires, screws, tape or a plate. 3,4,13,14,17 The majority of the surgical methods described have produced favourable clinical outcomes; however, complica- tions and morbidities appear almost inevitable. More recently, the use of a suture anchor was described for the treatment of complete Injury, Int. J. Care Injured 40 (2009) 1308–1312 ARTICLE INFO Article history: Accepted 12 March 2009 Keywords: Distal clavicle fractures Suture anchor Suture tension band Coracoclavicular ligaments ABSTRACT Objective: The study presents a surgical technique using two suture anchors combined with two non- absorbable suture tension bands and the clinical and radiological results obtained in patients with acute distal clavicle fractures associated with coracoclavicular ligaments disruption. Materials and methods: Nineteen patients with distal clavicle fractures were included with a mean follow-up of 25 months. All patients had type IIb fractures according to the Neer classification. Coracoclavicular ligaments were reconstructed using two suture anchors to maintain distal clavicle in an anatomical position, and supplementary interfragmentary fixation was performed using two non- absorbable suture tension bands in figure-of-eight configurations. Functional outcomes were assessed at final follow-up visits using the Constant score. Results: The numbers of lateral fragments averaged 1.4. Seventeen patients maintained the same vertical coracoclavicular distance between both shoulders. However, in two patients, the coracoclavicular distance of the injured shoulder increased by 50% compared with that of the contralateral shoulder. Fracture union was obtained in 18 patients at a mean 4.8 months postoperatively. One patient had symptomatic nonunion until 9 months postoperatively, and subsequently, distal clavicle resection was performed. Two patients showed delayed union and achieved fracture union at 9 and 10 months postoperatively, respectively. Clavicular erosion was found in two patients. The lateral fragment of one patient united in an upward angulated position caused by over-tightening of the medial clavicle. The average Constant score improved to 94. Conclusion: Coracoclavicular reconstruction using two suture anchors and supplementary interfrag- mentary fixation using two non-absorbable suture tension bands for acute distal clavicle fracture are reliable techniques for restoring stability in patients with acute distal clavicle fracture. ß 2009 Elsevier Ltd. All rights reserved. * Corresponding author. Tel.: +82 2 2650 5010; fax: +82 2 2642 0349. E-mail address: [email protected] (S.-J. Shin). Contents lists available at ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury 0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.03.013

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Page 1: Treatment of unstable distal clavicle fractures using two suture anchors and suture tension bands

Injury, Int. J. Care Injured 40 (2009) 1308–1312

Treatment of unstable distal clavicle fractures using two suture anchors andsuture tension bands

Sang-Jin Shin *, Kwon Jae Roh, Jong Oh Kim, Hoon-Sang Sohn

Department of Orthopaedic Surgery, Ewha Womans University, School of Medicine, 911-1, Mok-Dong, Yangcheon-Ku, 158-710 Seoul, Republic of Korea

A R T I C L E I N F O

Article history:

Accepted 12 March 2009

Keywords:

Distal clavicle fractures

Suture anchor

Suture tension band

Coracoclavicular ligaments

A B S T R A C T

Objective: The study presents a surgical technique using two suture anchors combined with two non-

absorbable suture tension bands and the clinical and radiological results obtained in patients with acute

distal clavicle fractures associated with coracoclavicular ligaments disruption.

Materials and methods: Nineteen patients with distal clavicle fractures were included with a mean

follow-up of 25 months. All patients had type IIb fractures according to the Neer classification.

Coracoclavicular ligaments were reconstructed using two suture anchors to maintain distal clavicle in an

anatomical position, and supplementary interfragmentary fixation was performed using two non-

absorbable suture tension bands in figure-of-eight configurations. Functional outcomes were assessed at

final follow-up visits using the Constant score.

Results: The numbers of lateral fragments averaged 1.4. Seventeen patients maintained the same vertical

coracoclavicular distance between both shoulders. However, in two patients, the coracoclavicular

distance of the injured shoulder increased by 50% compared with that of the contralateral shoulder.

Fracture union was obtained in 18 patients at a mean 4.8 months postoperatively. One patient had

symptomatic nonunion until 9 months postoperatively, and subsequently, distal clavicle resection was

performed. Two patients showed delayed union and achieved fracture union at 9 and 10 months

postoperatively, respectively. Clavicular erosion was found in two patients. The lateral fragment of one

patient united in an upward angulated position caused by over-tightening of the medial clavicle. The

average Constant score improved to 94.

Conclusion: Coracoclavicular reconstruction using two suture anchors and supplementary interfrag-

mentary fixation using two non-absorbable suture tension bands for acute distal clavicle fracture are

reliable techniques for restoring stability in patients with acute distal clavicle fracture.

� 2009 Elsevier Ltd. All rights reserved.

Contents lists available at ScienceDirect

Injury

journa l homepage: www.e lsevier .com/ locate / in jury

Surgical treatment is often recommended for the management ofdisplaced fractures in the distal third of the clavicle caused by a highrate of nonunion following conservative treatment.7,21 Edwardset al.7 demonstrated a 30% rate of nonunion after non-operativemanagement. Moreover, an additional healing period of greater than6 weeks has been reported to be required for non-operativetreatments.23 These morbidities are attributable in part to fracturedisplacements caused by opposing forces acting on the fragments.The trapezius muscle, attached to the medial fragment, displaces themedial clavicle superiorly and the weight of the arm draws thelateral fragment inferiorly, which results in major displacement andnonunion. In addition, the severity of associated ligamentousdisruption, especially of the coracoclavicular (CC) ligaments, alsocontributes to nonunion.12 Distal clavicle fractures are also classified

* Corresponding author. Tel.: +82 2 2650 5010; fax: +82 2 2642 0349.

E-mail address: [email protected] (S.-J. Shin).

0020–1383/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.

doi:10.1016/j.injury.2009.03.013

according to the injuries of CC ligaments because the conoid andtrapezoid ligaments are important structures for the fracture-healing process.20 Biomechanical investigations have confirmedthat the CC ligaments primarily restrain vertical translation.6,10

Furthermore, if CC ligament disruptions are left untreated, thefracture fragments may be unstable and the risk of nonunionincreased. Therefore, the surgical treatment for distal claviclefracture should be considered to include reconstruction of disruptedCC ligaments to stabilise the clavicle from superior migration and toprovide an environment conducive with fracture union.

Although numerous surgical methods have been proposed, noconsensus has been reached yet regarding the optimal surgicaltreatment for displaced distal clavicle fractures. Various fixationtechniques have been used, including wires, screws, tape or aplate.3,4,13,14,17 The majority of the surgical methods describedhave produced favourable clinical outcomes; however, complica-tions and morbidities appear almost inevitable. More recently, theuse of a suture anchor was described for the treatment of complete

Page 2: Treatment of unstable distal clavicle fractures using two suture anchors and suture tension bands

S.-J. Shin et al. / Injury, Int. J. Care Injured 40 (2009) 1308–1312 1309

acromioclavicular (AC) joint dislocation.5,24 Suture anchors offerthe advantages of ease of use and improved pullout strength, andreduce the risk of neurovascular injury when passing the suturematerial underneath the coracoid process. Therefore, the authorsdevised a surgical technique using suture anchors to obtainfracture stability and eliminate the considerable risks of complica-tions posed by the hardware.

The purpose of this study was to present a surgical techniqueusing two suture anchors combined with two non-absorbablesuture tension bands and the clinical and radiological resultsobtained in patients with acute distal clavicle fractures associatedwith CC ligaments disruption.

Materials and methods

Nineteen patients with acute distal clavicle fractures weretreated with the devised technique using two suture anchors andsuture tension bands. All patients had type IIb fractures accordingto the Neer classification.20 There were 5 women and 14 men ofmean age 43.4 years (range, 17–70 years). The dominant shoulderwas involved in 12 patients. All patients underwent surgery within3 weeks of injury, with a mean time from injury to operation of 7.1days (range, 1–21 days). Two of the 19 patients had associatedinjuries including one fracture of both forearm bones and onelateral malleolar fracture, respectively. Fractures were caused by afall from height in seven patients, motor vehicle accidents in six,bicycle accidents in five and sports injuries in one.

Distal clavicle fracture was diagnosed based on clinical andradiological assessments. Clinical diagnoses were based on thepresence of a painful and palpable step off in distal clavicle areasconcerned after the traumatic episode. Preoperative radiologicalevaluations included antero-posterior (AP) and axillary views ofboth shoulders. Computed tomography (CT) was taken in all patientspreoperatively to identify comminution and the accurate position offracture fragments. Maintenance of reduction was determined bymeasuring the vertical distance between the upper border of thecoracoid process and the inferior cortex of the clavicle (CC distance)in preoperative and postoperative standard radiographs. CC distanceof the injured shoulder was compared with that of the contralateralshoulder. Radiographs were taken with shoulders fixed in the sameposition to avoid the influences of projection changes that may haveaffected interpretations of the outcome.

The average follow-up period was 25.9 months (range, 24–40 months). Functional outcomes were assessed at final follow-upvisits using Constant score and times required before returning towork. Radiological evaluations, which included both shoulder APand axillary views, were routinely performed at 3 weeks post-operatively and every 3 months thereafter until union was observed.Shoulder antero-posterior (AP) radiographs in a standing positionwith patients holding a 4 kg weight in each hand (both shoulderstress view) were available for all patients at 6-month postoperativevisits. All shoulders were supported in a sling for 3 weekspostoperatively to avoid excessive downward traction. An activerange of motion exercises of the elbows, wrists and hands werestarted at the first day postoperatively. Passive- and active-assistedshoulder exercises were initiated from 3 weeks postoperatively anda strengthening exercise program at 6 weeks postoperatively. Heavyuse of the affected arms and contact sports were not allowed for 3months following the procedure. The paired Student’s t-test in SPSS(version 16.0, Chicago, IL, USA) was used for statistical analysis.

Surgical techniques

The patient was placed in the beach-chair position, with theaffected shoulder draped free at the lateral edge of the table. Avertical skin incision was made from 2 cm medial to the AC joint

toward the lateral aspect of the coracoid process. The deltotra-pezoidal fascia was split in the coronal plane and the deltoidmuscle was released from the anterior edge of the distal one-thirdof the clavicle. Some of the deltoid and trapezius attachments tothe clavicle were found to have been stripped as a result of injury.Subsequently, the AC joint, the distal one-third of the clavicle andthe base of the coracoid process were exposed. The medial clavicleusually requires about 4 cm of exposure from the fracture edge.The base of the coracoid can be palpated without entirely exposingthe CC interval area.

After exposing the fracture site, two suture anchors with doublyloaded sutures were placed on the base of the coracoid process. A3.7-mm bioabsorbable suture anchor (Arthrex, Naples, FL, USA),preloaded with two strands of 2/0 Fiberwire sutures, was theninserted into the antero-lateral portion of the base of the coracoidprocess, where the trapezoid ligament is attached. The other sutureanchor was placed on the postero-medial portion of the coracoidprocess, where the origin of the conoid ligament lies. The stabilitiesof these two suture anchors were checked by pulling on thesutures. Two clavicular holes, which were related to postero-medial anchor, were drilled side by side in the mid-portion of theclavicle about 2 cm from the medial edge of the fracture using a1.6-mm Kirschner wire. The horizontal distance between thesetwo clavicular holes was about 1 cm; the holes were usually placedon the conoid tubercle and at points directly above the postero-medial suture anchor, so as to allow the clavicle to be pulledvertically down, thereby preventing superior displacements ofmedial fragments of the clavicle. Two suture strands of thepostero-medial suture anchor were passed together through oneclavicular hole, and the other two suture strands of the sameanchor were passed through the neighbouring hole using thelooped wire made of a 26-gauge wire. After the looped wire ispassed from superior to inferior clavicular holes, the end of thewire is extracted through the CC interval and the two suturestrands of the suture anchor are passed through the looped wire,which was then pulled back through the clavicular holes.Therefore, the suture strands of the postero-medial suture anchorwere oriented in the same direction as that of the conoid ligament.The passing procedure was repeated whenever suture strandswere passed through the clavicular holes.

With the fracture fragments held temporarily in the reducedposition, additional two clavicular holes were drilled for theantero-lateral anchor at the respective centres of the abutting endsof the medial and lateral fracture fragments. These clavicular holeswere placed far enough from each fracture edge (about 1 cm) toprevent the risk of fracture propagation. The horizontal distancebetween these two clavicular holes was about 1.5–2 cm, butchanged depending on the length of the lateral fragment. The samesuture-strand-passing procedure described above was performed,this time across the fracture line. Later, four clavicular holes weredrilled using a 2.0-mm Kirschner wire for making suture tensionbands to reinforce the reduction. First, two parallel clavicular holeswere drilled in the medial clavicle, anterior and posterior to theline connecting the middle two of the four drill holes placed for theanchor strands. An additional two drill holes were placed in thelateral fragment, likewise anterior and posterior, beyond thelateral-most hole already in place. Thereafter, two strands of 5/0Fiberwire sutures (Arthrex, Naples, FL, USA) were passed togetherthrough the four newly created clavicular holes in a figure-of-eightconfiguration. The pairs of suture strands of anchors were then tiedover the superior surface of the clavicle, starting from the medialsuture strand pair through to the lateral suture strand pair. Duringthe tying process, the distal clavicle was fixed in an anatomicposition. After confirming that the distal clavicle was in thereduced position, two strands of 5/0 Fiberwire sutures were tied inthe figure-of-eight configuration (Fig. 1). Distal clavicle resection

Page 3: Treatment of unstable distal clavicle fractures using two suture anchors and suture tension bands

Fig. 1. A schematic drawing of coracoclavicular ligaments reconstruction using two

suture anchors and interfragmentary fixation using nonabsorbable suture tension

bands in acute distal clavicle fracture.

Fig. 3. Clavicular erosion by the suture materials.

S.-J. Shin et al. / Injury, Int. J. Care Injured 40 (2009) 1308–13121310

was not performed during these procedures, and torn CC ligamentswere not repaired. The deltoid–trapezius muscle and fascia wererepaired securely over the distal clavicle.

Results

Based on plain radiographic measurements, preoperative CCdistance averaged 7.1 mm (range, 4.7–9.9 mm) for uninjuredshoulders and 14.0 mm (range, 6.9–22.6 mm) for injured shoulders(96% increase). Mean CC distance of the injured sides decreased tonearly the same as that of uninjured shoulders in immediatepostoperative radiographs (average 6.9 mm in injured and 7.0 mmin uninjured sides). However, at 3 weeks postoperatively, averageCC distance increased slightly by 5% compared to normal sides(7.9 mm in injured and 7.6 mm in the normal side). At 3-monthfollow-up visits, average CC distance was 7.5 mm (range, 5.9–12.1 mm) for injured and 7.1 mm (range, 4.9–8.8 mm) forcontralateral shoulders (6% increase), and at 6-month follow-upvisits, it was maintained at 6% (7.3 mm and 6.9 mm, respectively).These differences of CC distances between both shoulders weremaintained even in stress-view radiographs, and average CCdistance at 6-month follow-up visits was maintained throughoutthe remainder of the follow-up period. At final follow-up visits, 17patients (89%) had the same CC distances between both shoulders(Fig. 2A and B). In two patients (11%), the CC distance of the injured

Fig. 2. A. Preoperative radiograph of distal clavicle fractures associated with

coracoclavicular ligaments disruption (right shoulder). B. Postoperative radiograph

showing anatomical reduction of the distal clavicle.

shoulder increased by 50% compared with that of the contralateralshoulder. The CC distances of all patients in radiographs takentowards the end were significantly decreased compared to those inpreoperative radiographs (p < 0.05).

The number of distal fragments averaged 1.4 (six patients hadtwo or more lateral fragments). Fracture union was obtained in18 of 19 patients at a mean 4.8 months postoperatively (range,3–12 months). One patient (a 36-year-old man) had symptomaticnonunion until 9 months postoperatively, and subsequently, distalclavicle resection was performed. Two patients experienceddelayed union, but achieved union at 9 and 10 months post-operatively, respectively. Clavicular erosion by suture materialswas found in two patients (11%) (Fig. 3) and in both, slight erosionof the clavicle appeared within 6 months of fixation and remained

Fig. 4. Suture over-tightening caused the lateral fragment to unite in an upward

angulated position.

Page 4: Treatment of unstable distal clavicle fractures using two suture anchors and suture tension bands

S.-J. Shin et al. / Injury, Int. J. Care Injured 40 (2009) 1308–1312 1311

unchanged at the final follow-up. In one patient, the lateralfragment united in an upward angulated position caused by over-tightening of medial sutures, which led to over-reduction of themedial clavicle (Fig. 4). However, neither of these patients had anyclinical symptoms that adversely affected daily activities through-out follow-up. Post-traumatic AC arthritis and calcificationbetween the coracoid process and the inferior border of the distalclavicle were encountered in any given patient.

The mean Constant score of all patients was 94 (range, 88–100)at final follow-up evaluations. All patients returned to a normal lifeat a mean 4.6 months (range, 2.6–6.2 months) postoperatively.Two of the 19 patients (11%) showed mild internal rotation andforward flexion limitation, respectively, and two other patients(11%) complained of mild discomfort while performing heavylabour. No suture anchor was found to have been pulled out of thecoracoid process during follow-up.

Discussion

In the present study, the authors obtained satisfactory clinicaloutcomes without any serious complications using two sutureanchor fixation augmented with suture tension bands technique inpatients with acute distal clavicle fractures associated with CCligaments disruption. This devised surgical technique restored theanatomical reduction and provided sufficient strength to hold thedistal clavicle to the coracoid process securely enough to achieveCC ligaments and fracture healing.

Current surgical treatments achieved distal clavicle stabilisa-tion by direct osteo-synthesis, CC interval fixation or transacromialfixation.4,11,12,15 The stabilisation of the distal clavicle by fixationacross the AC joint has been described using various types ofhardwares.8,14,16 However, percutaneous fracture fixation istechnically demanding because of the anatomical relationshipbetween the thin acromion and the curved shape of the distalclavicle, and the use of metal hardware across the AC joint is ofparticular concern, because of the possibility of intra-articularinjury leading to degenerative arthritis.16 Furthermore, anyinternal fixation crossing the AC joint has the possibility ofbreakage and migration to other organs, because it interferes withthe physiological rotation of the clavicle with respect to theacromion.22 Distal clavicle fracture stabilisation can be achievedthrough the base of the coracoid process and the medial clavicularfragment fixation using screws, various types of tape orsutures.4,11,13 The simple loop technique in the CC interval iseffective when applied in a long, oblique fracture fragment of thelateral clavicle. However, the number of long and oblique-patterned distal clavicle fractures is rather small and this loopmethod, when used alone, is inadequate in terms of overcomingthe muscle forces applied to the fracture fragments. Thus, toprevent loss of correction, the loop technique is usually performedwith additional fixation.4,11 Furthermore, loop materials like wiresand non-absorbable bands around the clavicle may lead to gradualerosion and possible pathological fracture.18 On the other hand,simple CC loop techniques around the coracoid process cause thefinal position of the distal clavicle to be displaced anteriorly withrespect to its anatomic position. Because the normal anatomy ofthe clavicle is directly superior to the base of the coracoid process,rigid fastening of the clavicle to the waist of the coracoid processcauses abnormal anterior translation of the clavicle.19 In addition,passing loop materials around the undersurface of the coracoidprocess can also lead to neurovascular injuries. Alternatively,osteo-synthesis of distal clavicle fracture can be achieved using aplate and screws.15,25 Clavicular plates offer the potentialadvantage of avoiding the AC joint, are stronger than K-wirefixation and are most commonly used when the distal fragment islong enough to hold at least two bicortical screws.1,9 However, the

plating of fractures may not be possible, particularly when thelateral fragment is small or comminuted. Moreover, plate fixationcan also be associated with stress shielding and re-fracturerequiring an additional surgical procedure for hardware removal isalso a possibility.2

No optimal method of surgical fixation has been established forunstable distal clavicle fractures, though the authors consider thatCC ligament reconstruction provides an important means ofachieving stability and for improving clinical outcomes. Serialligament-cutting experiments have also revealed that the twocomponents of the CC ligaments provided superior and anteriorstability of the distal clavicle.6 In this study, the authors obtainedsuccessful fracture union in an anatomic position by CCreconstruction using two suture anchors and interfragmentaryfixation by using two non-absorbable suture tension bands inpatients with acute displaced distal clavicle fractures with CCligaments disruption. Medial clavicle fragment was held securelyby two suture anchors, which maintained adequate reduction,while interfragmentary fixation was achieved using double strandsof non-absorbable sutures in figure-of-eight configurations. Thepostero-medial suture anchor plays an important role byrestraining the medial clavicle from vertical displacement inposition of the conoid ligament.

Stabilisation of distal clavicle fracture using suture anchorsoffers further advantages. First, accessing the top of the base of thecoracoid process is easier and less dangerous to neurovascularstructures than passing a loop underneath the coracoid process.Suture anchors can be placed, in relation to the clavicle andcoracoid process, in such a way as to avoid anterior displacement,which is frequently encountered when the loop technique is used,as a result of anatomical mismatch. Using the described technique,there is enough room to insert two anchors even in a small coracoidprocess when 3.7-mm suture anchors are used, and problems, suchas fracture of the coracoid process or anchor pullout caused byinadequate placement, are thus avoided. In addition, the techniquerequires smaller clavicular holes than are needed for looptechniques or screw fixation, which minimises the possibility ofpathological fracture. Although a small number of vertical CCdistance widening were encountered in the present study, twosuture anchors appear to have sufficient strength to preventsuperior migration of the clavicle. This makes temporary arthrod-esis of the AC joint unnecessary, thereby preventing secondarydamage to joint cartilage and the hardware problems that can ariseduring transarticular fixation. Finally, no additional interventionwas necessary for hardware removal, and thus, the devisedtechnique appears to be free of hardware complications. For thesereasons, the use of suture anchors for distal clavicle reduction wasproposed as an alternative to CC sling-type reinforcement. Bezeret al.3 used a single suture anchor placement to the coracoidprocess combined with pin fixation across the AC joint to treatdistal clavicle fractures and obtained satisfactory clinical out-comes. However, they also reported some complications asso-ciated with transarticular pinning. Therefore, in the present study,a suture tension band technique was used for interfragmentaryreinforcement. Double strands of non-absorbable sutures in figure-of-eight configurations approximate fracture fragments securelyand provide mechanically sound fracture fixation to facilitateunion. Levy devised a similar technique consisting of a figure-of-eight superior tension band between fragments using doubleabsorbable sutures, but this method is restricted to distalfragments connected to the CC ligaments.17

The disadvantage of the described technique is that it is difficultto control tension when tying the sutures. In one patient, thefracture was united in an upward angulated position because of afailure to control tension between fragments. Concerns have beenraised regarding the possibility of osteolysis at points of contact

Page 5: Treatment of unstable distal clavicle fractures using two suture anchors and suture tension bands

S.-J. Shin et al. / Injury, Int. J. Care Injured 40 (2009) 1308–13121312

between sutures and the clavicle when suture anchors with non-absorbable sutures are used for CC fixation. In the present study,slight erosion of the clavicle by the suture materials was found intwo patients. Slight widening of the vertical CC distance occurredin another two within 3 weeks of operation. Therefore, 3 weeksappears to be an appropriate period before directing patients tobegin the shoulder range of motion exercises. Nevertheless, theradiological degree of CC interval widening and bony erosion of thefracture area do not appear to be closely related to fracture unionand regaining adequate shoulder function. Sometimes, when distalfragments are small, they can be comminuted while drilling holesfor the double strands of non-absorbable sutures. However, in thissituation, two strands of antero-lateral suture anchor can hold thedistal fragment instead and lateral fragments are usually stablebetween the medial clavicle and an intact AC joint. Although theproposed CC reconstruction technique produced successful clinicalresults for the treatment of acute AC dislocation, furtherbiomechanical investigations are required regarding the stiffnessand elongation of suture anchors.

Conclusion

No single current surgical technique has been demonstrated toobtain superior results over other forms of fixation. The authorsconsider that two suture anchor fixation combined with suturetension bands technique is an alternative for the surgical treatmentin patients with acute distal clavicle fractures associated with CCligaments disruption. CC reconstruction using two suture anchorsand supplementary interfragmentary fixation using two non-absorbable suture tension bands for acute distal clavicle fractureare reliable techniques for restoring stability in patients with acutedistal clavicle fracture.

Conflict of interest statement

The authors did not receive grants or outside funding in supportof their research or preparation of this manuscript. They did notreceive payments or other benefits or a commitment or agreementto provide such benefits from a commercial entity.

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