REVIEW ARTICLE
Hook Plate Fixation for Acute Unstable Distal Clavicle
Fracture: A Systematic Review and Meta-analysis
Saeed Asadollahi, MD, FRACS* and Andrew Bucknill, MBBS, Msc, FRCS, FRACS*,†
Objectives: To compare the outcome of hook plate fixation with
other techniques in surgical fixation of acute unstable distal clavicle
fractures.
Data Sources: In July 2018, a systematic search of electronic
databases (PubMed, Medline, Embase, and Cochrane databases for
systematic reviews) was performed according to the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses guide-
line. Articles were limited to English language.
Study Selection: Studies were included if they compared the
results of hook plate fixation of acute unstable distal clavicle fracture
in adults with other surgical techniques.
Data Extraction: Data on the study setting, functional outcome,
union, and complication rates were extracted. A quality assessment
was performed using the Newcastle–Ottawa Scale.
Data Synthesis: Eleven studies were found that met the inclusion
criteria. Six hundred thirty-four patients were pooled using a random
effects model. There were 397 male and 237 female patients.
Primary outcome measure was functional result, and the secondary
outcome measures were union and complication rates. There was no
significant difference between the functional outcome and union rate
between hook plate fixation, coracoclavicular (CC) stabilization, and
locking plate fixation. Hook plate fixation resulted in a higher
Constant–Murley score compared with tension band wiring (TBW)
[odds ratio (OR), 3.52; 95% confidence interval (CI), 0.79–6.26]. It
was also associated with a higher complication rate compared with
CC stabilization (OR, 3.68; 95% CI, 1.19–11.33) and the locking
plate (OR, 5.19; 95% CI, 1.58–17.06). Compared with TBW, hook
plate fixation was associated with a lower complication rate (OR,
0.28; 95% CI, 0.10–0.77).
Conclusions: Hook plate fixation achieves a similar functional
outcome and union rate compared with CC stabilization and locking
Accepted for publication March 1, 2019.
From the *Department of Orthopaedic Surgery, The Royal Melbourne Hospi-
tal, Parkville, Victoria, Australia; and †Department of Surgery (RMH), The
University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria,
Australia.
The authors report no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jorthotrauma.
com).
Reprints: Saeed Asadollahi, MD, FRACS, Department of Orthopaedic
Surgery, The Royal Melbourne Hospital, Parkville, Victoria 3050,
Australia (e-mail: saeedasadollahi@yahoo.com).
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DOI: 10.1097/BOT.0000000000001481
J Orthop Trauma  Volume 33, Number 8, August 2019
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
plate fixation. However, it has a superior functional result compared with
TBW. The complication rate is higher compared with CC stabilization
and locking plate fixation and is lower compared with TBW.
Key Words: clavicle, hook plate, systematic review, meta-analysis
Level of Evidence: Therapeutic Level III. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2019;33:417–422)
INTRODUCTION
Distal clavicle fractures account for 10%–30% of all clavicle
fractures.1 Nonoperative treatment of unstable distal clavicle frac-
tures is associated with a high rate of nonunion,2–4 and therefore,
surgical fixation is recommended as the treatment of choice.
Several techniques have been described for the opera-
tive fixation of distal clavicle fractures. They include the hook
plate,5 locking plate,6 coracoclavicular (CC) fixation,7 tension
band wiring (TBW),8 Kirschner wire and Knowles pins,9–11
endobutton,12 and modified Weaver-Dunn.13 Each technique
has its advantages and disadvantages.14 None of the fixation
techniques is established as the “gold standard.”15
Hook plate fixation is a widely used technique for the
fixation of unstable distal clavicle fracture.5,16 Multiple stud-
ies have reported the outcome of hook plate fixation17–22;
however, there have only been a few studies comparing the
result of hook plate fixation with other techniques.10,16,23–29
To date, neither qualitative nor quantitative analysis has been
performed on these studies.
Although randomized controlled trials provide the
highest quality of evidence, such studies are limited in
surgical literature because designing and conducting surgical
trials can be challenging or sometimes logistically impossible
due to the rarity of the case.30
The objective of this study was to analyze and compare
the functional outcome, union rate, and complications
associated with hook plate fixation versus other techniques.
The hypothesis of this study was that CC stabilization of
acute unstable distal clavicle fracture results in a higher
functional outcome and lower complication rate compared
with other available techniques.
METHODOLOGY
This systematic review and meta-analysis were conducted
according to the guidelines set by the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses.31
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Asadollahi and Bucknill
FIGURE 1. Flow chart of the selection
of papers.
Search
In July 2018, a search of electronic databases including
Medline (1946 to July 2018), Embase (1974 to present),
PubMed, and the Cochrane Library was performed. We used
a combination of Medical Subject Headings: “clavicle,” “frac-
ture fixation,” “fracture,” “bone,” “adult” and also text words
for “lateral clavicle fracture,” “internal fixation,” “distal clav-
icle fracture,” “hook plate,” “locking plate,” “acute,” and
“coracoclavicular” that appeared in the abstracts and titles.
The reference sections of all articles accessed were screened
for any undetected studies, and an English language restric-
tion was applied.
Study Selection
Studies were shortlisted if they were related to the
surgical fixation of acute unstable lateral clavicle fracture in
adults. The abstracts of the shortlisted studies were reviewed,
and selected abstracts were considered for full-text review.
We included all studies that compared hook plate fixation
with other techniques in the surgical treatment of acute
unstable distal clavicle fracture. Case series, case reports,
and studies dealing with midshaft or medial clavicle fracture
were excluded.
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J Orthop Trauma  Volume 33, Number 8, August 2019
Data Extraction/Outcome of Interest
Data were extracted by one author (S.A.). A database
was created including the information on the study design,
patients’ demographics, type of distal clavicle fixation, follow-
up, functional outcome, union, and complication rates. Symp-
tomatic hardware removal was not recorded and analyzed as
a complication in this review. The second author (A.B.)
checked the accuracy and completeness of the primary data.
Quality Assessment
Study quality was evaluated using the Newcastle–
Ottawa Scale (NOS).32 The NOS is a simple quality assess-
ment tool for the appraisal of case–control and cohort stud-
ies.32 In NOS, study quality is assessed based on 3 items: (1)
selection of study groups, (2) comparability of study groups,
and (3) exposure. Stars are given for each category and serve
as a visual analogue assessment, with 9 stars indicating the
highest quality. Also, NOS has been recommended by the
Cochrane Collaboration for quality assessment.33
Statistical Analysis
The data from each study was extracted and analyzed
using Review Manager 5.3 (The Cochrane Collaboration,
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J Orthop Trauma  Volume 33, Number 8, August 2019 Distal Clavicle Fracture Hook Plate Fixation

TABLE 1. Description of Included Studies

Year Study Fracture Type Number Comparison Groups Male/Female Right/Left Mean Follow-up (mo)
2018 Hsu et al23 Neer II and V 72 Hook plate vs. CC loop technique 45/27 Incomplete data 14
2017 Erdle et al14 Neer IIB 32 Hook plate vs. locking plate 4/28 15/17 54
2017 Yan et al25 Neer II 42 Hook plate vs. CC reconstruction 29/13 10/32 26
2015 Flinkkilä et al16 Neer II 40 Hook plate vs. TightRope 33/7 10/30 46
2014 Chen et al27 Neer IIB 68 Hook plate vs. CC suture fixation 44/24 Not reported 38
2014 Zhang et al34 Neer II 66 Hook plate vs. locking plate 37/29 39/27 28
2012 Tan et al26 Neer II 42 Hook plate vs. locking plate 28/14 27/15 22
2011 Wu et al28 Neer II 116 Hook plate vs. TBW 72/44 Not reported 28
2010 Hsu et al24 Neer II 65 Hook plate vs. TBW 46/19 43/22 6
2009 Lee et al10 Neer II 52 Hook plate vs. TBW 27/25 Not reported 26
2002 Flinkkilä et al29 Neer II 39 Hook plate vs. TBW 32/7 Not reported 52

Copenhagen, Denmark). The random effects model was used
for data pooling. For dichotomous variables, the odds ratio
(OR) and 95% confidence intervals (CIs) were calculated.
Where the 95 percent CI included 1, the result is considered
not statistically significant. For continuous variables, the
weighted mean difference (WMD) and 95% CIs were
calculated. Any WMD interval that included zero was
considered not statistically significant.
RESULTS
A total of 714 articles were identified in the initial search
(Fig. 1). After removing the duplicate records, 698 records
were screened, 674 of which were excluded. The full texts of
the remaining 24 articles were reviewed. Eleven studies met
the inclusion criteria. Table 1 outlines the characteristics of the
included studies. The total number of patients was 634. Of
these, 397 were male and 237 were female patients. Nine
studies were retrospective comparative studies,10,14,16,23,26–
29,34 and 2 were prospective randomized trials.24,25
The results of the quality assessment performed on the
studies are shown in Table 2. In all studies, the 2 groups were
matched at least for age and sex. Some studies also matched the
groups for fracture side,16,23–26,34 associated comorbid-
ities,10,23,24 trauma mechanisms,10,27,28 time from injury to
operation,16,25–27 length of lateral fragment,14 fragment count,14
CC distance deviation,14 and follow-up period.10,14,16,23,26,27,34
For the purpose of meta-analysis, we divided the
studies into 3 main surgical technique groups: (1) hook plate
fixation, (2) CC stabilization, and (3) TBW group. The
Constant–Murley score was used for the analysis of the
functional result, as it was the most commonly used outcome
assessment tool among the studies. The study by Hsu et al24
was not included in the functional outcome analysis due to its
short-term follow-up (6 months). In this study, the hook plate
was not removed at the time of assessment, which potentially
underestimates the shoulder function score.26
Fig. 2 shows the functional outcome following hook
plate fixation compared with other techniques. There was
no significant difference in the functional result following
hook plate fixation compared with CC stabilization and lock-
ing plate. However, hook plate fixation was associated with
a higher Constant–Murley score compared with TBW (mean
difference, 3.52; 95% CI, 0.79–6.26).
There was no significant difference in the union rate for
the post hook plate fixation compared with other techniques
(Fig. 3). However, the complication rate associated with hook
plate fixation was significantly higher compared with that
associated with CC stabilization (OR, 3.68; 95% CI, 1.19–
11.33) and locking plate (OR, 5.19; 95% CI, 1.58–17.06)

TABLE 2. Quality Assessment of Included Studies

NOS Rating
Year Study Level of Evidence Selection Comparability Exposure
2018 Hsu et al23 III ✯✯✯✯ ✯✯ ✯✯✯
2017 Erdle et al14 III ✯✯✯✯ ✯✯ ✯✯✯
2017 Yan et al25 II ✯✯✯✯ ✯✯ ✯✯✯
2015 Flinkkilä et al16 III ✯✯✯✯ ✯ ✯✯✯
2014 Chen et al27 III ✯✯✯✯ ✯✯ ✯✯✯
2014 Zhang et al34 III ✯✯✯✯ ✯ ✯✯✯
2012 Tan et al26 III ✯✯✯ ✯ ✯✯✯
2011 Wu et al28 III ✯✯✯✯ ✯ ✯✯✯
2010 Hsu et al24 II ✯✯✯✯ ✯✯ ✯✯
2009 Lee et al10 III ✯✯✯✯ ✯✯ ✯✯✯
2002 Flinkkilä et al29 III ✯✯✯ ✯ ✯✯✯

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Asadollahi and Bucknill
FIGURE 2. Forest plot of functional outcome analysis of hook plate compared with (A) CC stabilisation, (B) Locking plate, and (C)
TBW fixation.
(see Figure, Supplemental Digital Content 1, http://links.
lww.com/JOT/A686). Hook plate fixation was associated
with significantly lower complications compared with TBW
(OR, 0.28; 95% CI, 0.1–0.77).
DISCUSSION
Hook plate fixation is a reliable technique for distal
clavicle fracture surgical treatment.21 The subacromial hook
provides distal leverage that allows the reduction of the supe-
riorly displaced medial fragment. Our findings are in line with
previous reports showing that hook plate fixation achieves
a comparable functional outcome and high union rate similar
to other techniques.15,35 However, the hook contact can pre-
dispose to subacromial space inflammation, rotator cuff
impingement, acromion osteolysis and fracture.15,22,25,36,37
Subacromial position of hook of the hook plate and its
leverage force predisposes specific subset of complications
manifesting as shoulder pain and limited range of move-
ment.15,22,25,36,37 The most common complications following
hook plate fixation in this review (n = 59) were subacromial
osteolysis or erosion (27%), acromioclavicular arthrosis (22%),
and peri-implant fracture (22%). How to improve the design of
the hook plate or finding the ideal time to remove it before
complication occurs can be the focus of future studies.
Various methods of CC stabilization have been
described in the literature.16,23,25,27 Compared with hook
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J Orthop Trauma  Volume 33, Number 8, August 2019
plate, potential advantages of CC stabilization are avoiding
the need for implant removal and other potential complica-
tions, such as rotator cuff impingement and acromial frac-
ture.37 The result of the current meta-analysis confirms this
with the odds of complication being 3.68 times less after CC
stabilization compared with those after hook plate fixation.
Locking plates rely on multiple screw fixations in the
distal fragment to restore CC stability.17 The anatomical
design and low-profile plate reduces the potential need for
plate removal.38 Although the complication rate associated
with locking plate fixation is lower than that associated with
hook plate, locking plate alone may not be suitable for a very
distal fracture, comminuted fracture, or osteoporotic bone,
where the distal fragment cannot hold screws. Under these
circumstances, plate fixation combined with CC stabilization
can be used to reduce fixation failure.38
Tension band wire fixation using transarticular or extra-
articular K-wire is one of the earliest described techniques for
the fixation of unstable distal clavicle fracture.10 Our findings
show that TBW can achieve a functional outcome similar to
hook plate fixation. The 3.52 WMD in the Constant–Murley
score between the TBW and hook plate fixation, although
statistically significant, is less than the minimum clinically
important difference of 10.4 to show any clinical signifi-
cance.39 However, the present meta-analysis shows that the
odds of complication occurring with TBW are 3.2 times higher
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J Orthop Trauma  Volume 33, Number 8, August 2019
FIGURE 3. Forest plot of union rate following hook plate fixation compared with (A) CC stabilisation, (B) Locking plate, and (C)
TBW fixation.
compared with those occurring with hook plate fixation. This is
in line with previous reports that found the complication rate
associated with TBW to be unacceptably high.10,28,40
The meta-analysis of observational studies combines
results that are clinically and methodologically diverse.41 Our
systematic review shows that the confounding factors and
matched variables between the comparison groups were not sim-
ilar in all studies. The outcome assessment tool and methods of
presenting data were not always consistent in the included stud-
ies. However, to our knowledge, this meta-analysis offers the first
combined synthesis of available evidence comparing the out-
come of hook plate fixation with other techniques in the treat-
ment of unstable distal clavicle fractures. A randomized
controlled study with a large number of participants is necessary
to compare the result of hook plate with other fixation techniques.
In conclusion, there is lack of high-quality evidence
comparing the outcome of hook plate fixation with other
techniques in the surgical treatment of acute unstable distal
clavicle fracture in adults. Hook plate fixation achieves greater
functional result compared with TBW. However, it has a similar
functional outcome and union rate compared with CC
stabilization, and locking plate. The complication rate
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Distal Clavicle Fracture Hook Plate Fixation
associated with hook plate fixation is higher compared with
that associated with CC stabilization and locking plate and
lower compared with that associated with the TBW technique.
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