Review Article

HAND and Hand Microsurg 2020;X:X-X

1 MICROSURGERY doi:10.5455/handmicrosurg.83890 1
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8 Unstable distal clavicle fractures (Neer Type II): A review of the 8
9 complications and functional outcomes among treatment modalities 9
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Kemal Gokkus, Mehmet Sukru Sahin, Baris Sargin
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13 ABSTRACT 13
14 Objectives: To perform a systematic review of the literature on unstable distal claviclefractures in order to determine the preferable 14
treatment method.
15 Data sources: A literature search for articles (written in English or abstracted in English) on keywords “distal clavicle fracture treat- 15
ment” published between January 1990 and december 2019 was reviewed from the Pub -Med database.
16 Study selection: A bibliographical review of the included articles was performed to find omitted studies. Studies dealing with
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17 non-union (pseudo-arthrosis) and arthroscopic methods were excluded. Open fractures, pediatric fractures, mid-shaft, medial clavi- 17
cle fractures, and complicated cases were excluded. Non-English articles without an English abstract were excluded. Eighty-three
18 (83) articles representing 2044 surgeries were selected. 18
19 Data extraction: The manuscripts were classified in accordance with their level of evidence and surgery type. All manuscripts 19
were closely examined with regard to functional scores (including Constant scores, UCLA and ASES, etc scores), union rates and
20 complication rates. 20
21 Data synthesis: The mean union rate, complication rate, and mean functional scores were calculated for each treatment modality. 21
The extracted data were accumulated and the mean rates were calculated to evaluate and compare different treatment modali-
2 ties. The means of the groups were analyzed using analysis of variance (ANOVA) and the Bonferroni post hoc test. The pearson 2
correlation coefficient was used to analyze whether a significant correlation exists between the parameters. Two-tailed hypothesis
23 was considered in the analyses, and the significant differences were accepted if p value was .05 or less. SPSS 18.0 software for
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24 Windows (SPSS, Inc., Chicago, IL, USA) was used in the evaluation of statistical analyses. 24
Results: A total of ten types of treatment modalities was compared according to results of constant scores, union rates and com-
25 plication rates. ANOVA test results showed significant differences between the groups with respect to union rate and complication
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26 rate (p=0.000 and p=0.000 respectively), while there were no statistically significant differences between the groups regarding to 26
constant scores (p= 0.264). According to Bonferroni post hoc test the differences were caused by conservative treatment modalities
27 in both union and complication rates. Regarding Pearson correlation test; there were no statistically significant correlation between 27
28 constant scores with other scores (p=0.558, r=0.071 and p= 0.187, r= -0.176 for union rate and complication rate respectively). 28
However, there were statistically significant negative correlation between union and complication rates (p=0.000, r= -0.424).
29 Conclusions: There is no difference between the surgical treatment methods, the conservative treatment method was found to be 29
30 statistically different (worse) than all other methods. 30
When the treatment modalities were arranged according to highest results of constant scores, union rates and the lowest scores
31 of complication rates ; the distal clavicle anatomic plate (precontoured plate) with /without CC sling and CC-sling (alone) were the 31
most preferable modalities according to benefited result relation. Thus, these techniques might be preferable.
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Key words: Distal clavicle fracture, lateral end clavicle fracture, neer type II distal clavicle fracture, unstabledistal clavicle fracture
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35 Introduction aments relative to the fractured fragments, as both the 35
36 Fractures on the distal third of the clavicle account conoid and trapezoid ligaments play an extensive role 36
37 for 12-15% of all clavicular fractures and are classified in fracture healing [1-4]. 37
38 based on the location of the coracoclavicular (CC) lig- Allman [5] classification with Neer's [1] Modifi- 38
39 Author affiliations : Department of Orthopaedics and Traumatology, Baskent University School of Medicine, Alanya Research and Practice Center, Antalya, Turkey 39
Correspondence : Kemal Gokkus, MD, Department of Orthopaedics and Traumatology, Baskent University School of Medicine, Alanya Research and Practice
40 Center, Antalya, Turkey. e-mail: kgokkus@gmail.com 40
Received / Accepted : February 02, 2020 / September 20, 2020

© 2020 Turkish Society for Surgery of the Hand and Upper Exremity www.handmicrosurgeryjournal.com
 Gokkus K et al.

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25 Figure 1. Illustration of the Neer classification system. 25
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27 cation for distal fractureswas used commonly in litera- evaluate the evidence regarding the preferable treat- 27
28 tures. The summary of this classification were illustrat- ment method for unstable distal clavicle fractures 28
29 ed in figure 1. (See figure 1) (Neer’s Type II) by performing a systematic review of 29
30 CC ligament restraint loss on the medial fragment the union rate, functional scores, and complications as- 30
31 causes fracture displacements, which contributes to an sociated with various treatment modalities [7-105]. 31
32 increased risk of pseudarthrosis and imperfect union Methods 32
33 compared to that of mid-shaft clavicular fractures [1-6]. Data sources 33
34 Surgical treatment is indicated in such cases due to diffi- A literature search was performed in the PubMed 34
35 culties in stabilizing reduction without an external inter- database using the search terms: Distal clavicle frac- 35
36 vention [1,2,7,8]. Although many operative procedure turetreatment, Lateral end clavicle fracture, Neer’s type 36
37 methods exist for unstable clavicular fractures, none are II distal clavicle fracture and unstable distal clavicle 37
38 considered to be the “gold standard” and optimal treat- fracture. The search was filtered for articles written in 38
39 ment is still an ongoing debate in the medical community. English that were published between 1st January 1990 39
40 The main objective of the present study was to and December 31st 2019. 40

XX | Hand and Microsurgery Year 2020 | Volume X | Issue X | X-X

 Unstable distal clavicle fractures (Neer Type II): A Review

1 Study eligibility criteria we closely examined the results of each study within 1
2 Exclusion Criteria the scope of union rate, Constant shoulder score, com- 2
3 The clavicular fractures regarding to the mid-shaft plication rate (Table 1) Regarding the complication 3
4 and medial sidewere excluded from this study. rate calculation, we closely evaluated the results of each 4
5 The articles concerning pure AC joint injuries (dis- study and separated the comparative studies to ease the 5
6 location), the articles concerning complications, case evaluation of each part on its own and gathered all data 6
7 reports, the articles concerning arthroscopic treatment together within the scope of complication. The compli- 7
8 of the distal clavicular fractures, other various studies cations were noted from the articles and divided into 8
9 which were screened by keywords, but actually not re- total patient number of each treatment modality. All re- 9
10 lated with adult distal clavicular fracture treatment, the ported complications from skin irritation to re-fracture 10
11 articles concerning tumor lesions of this region were ex- and non-union were taken into consideration. Regard- 11
12 cluded from this study. The Non-English articles which ing the calculation of the mean functional scores of the 12
13 were fitted to our keywords without English abstracts shoulder in terms of Constant's Score (The equivalence 13
14 and the abstracts that fitted with our keywords which of the other scales to Constant's score), we equalize 14
15 were published in supplements (oral presentation or each score by dividing the reported score to own max- 15
16 poster presentations) were excluded from this study(- imum value for example, in Ynag et al. study [22] they 16
17 Figure 2). The articles concerning CC reconstruction, reported the mean functional score in terms of UCLA 17
18 surgical technique andnon-union or pseudo arthrosis scale (the mean score was reported as 34 in terms of 18
19 treatments were excluded from this study. The three UCLA scale), we divide 34 to 35 and equalize the score 19
20 groups (1. Intramedullary 4.5 mm AO/ASIF malleolar into 100 units number. The equivalence of this value 20
21 screw/single, cortical screw, 2. Suturing techniques, 3. resulted as 97.1 in 100 units number. We accepted this 21
22 Micromovable acromioclavicular plate) were excluded value as the mean functional scores of the shoulder in 22
23 from the general assessment and statistical analysis be- terms of Constant's Score (The equivalence of the oth- 23
24 cause they had low number of cases .But we presented er scales to Constant’s score).The analyzed articles and 24
25 their results to avoid defragmentation of our review. their total mean scores with their statically significance 25
26 Inclusion criteria and grouping were listed in Table 2. 26
27 The keywords “distal clavicle fracture treatment” Statistical analysis 27
28 was enrolled. The articles we obtained from keywords Mean and standard deviation were calculated for 28
29 were subjected to exclusion criteria in our study, 98 ar- descriptive statistics of continuous variables and median 29
30 ticles were obtained from the keyword “distal clavicle values for discrete variables. The Kolmogorov-Smirnov 30
31 fracture treatment”(See figure 2). In total 98 articles test was used to analyze the normality of the data. The 31
32 were closely examined,the represented singular and means of groups were analyzed using analysis of vari- 32
33 combined techniques are listed in Table 1 along with the ance (ANOVA) and then Bonferroni post hoc test. 33
34 associated references and the reported total number of The Pearson correlation coefficient was used to analyze 34
35 patients. The articles that had no quantitative measure- whether a significant correlation exists between the pa- 35
36 ment of shoulder score (such as ASES, DASH, Constant, rameters. Two-tailed hypothesis were considered in the 36
37 etc ) were excluded from the data that would enroll into analyses, and the significant differences were accepted if 37
38 the statistics . However the number of the articles that p value was .05 or less. SPSS 18.0 software for Windows 38
39 were subjected to statistics decreased into 83. (SPSS, Inc., Chicago, IL, USA) was used in the evalua- 39
40 To analyze the clinical outcomes of each treatment, tion of the statistical analyses. 40

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 Unstable distal clavicle fractures (Neer Type II): A Review

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 Gokkus K et al.

1 Table 1. The summary of the mean constant scores, union rates, and complication rates along with the treatment methods and the reported 1
2 total number of patients. (Sequenced from the highest to lowest according to Constant scores) 2
The mean The mean
3 Group Constant
The mean
Complication
3
Union rate
4 score rate 4
5 TBW +CC sling [21,27,35,59,80, 82,88] (96 patients) 95,65 95,5 18,7 5
CC- sling [18,22,40,48,50,52,61,67,85,90,92,97,98,99] (244 patients ) 93,24 95,55 10,13
6 6
Conservative treatment [7,68,67,70] (133 patients) 92,75 68,03 59,43
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Distal clavicle anatomic plate [13,19,20,25,26,41,44,45,58,59,77,79,86,96,100,101,102,103]
8 90,97 99,85 10,0 8
(341 patients)
9 Precontoured plate +CC sling [11,13,15,23,16,59,77,80,81,84,87,100,104] (178 patients) 91,11 98,65 12,21 9
10 CC sling +transacromial extra articular knowless pin / k-wire [62,28,79] (41 patients) 88,77 97,33 33,78 10
11 Hook plate [9,18,20,23,25,29,30,36,39,46,47,53,57,64,65,69,71,75,84,85,87,90,94,95,96] 11
88,21 93,16 38,7
(637 patients )
12 Trans acromial knowless pin /K-wires or IM (extra-articular) Knowles pin [7,31,32,37, 63,105]
12
87,70 92,31 40,14
13 (144 patients) 13
14 TBW with/ without K-wire [8,9, 24,36,37,42,59,64,91] (167 patients ) 90,61 97,8 19,56 14
Bosworth Techninique [7,10,38,51,60,66,76] (107 patients) 95,57 99,16 10,16
15 15
Total mean (2088 patients) 90,76 95,33 22,81
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17 17
18 18
Table 2. Treatment methods and their evaluations regarding the functional shoulder score, union rate and complication rate.
19 19
20 20
CC-sling transacromial

Knowless pin single or

21 TBW with-without 21
22 22

TBW+ CC-sling
anatomic plate

plate+CC sling
double K-wire

Pre-contoured

Transacromial
Distal clavicle
extrearticular

extraarticular
Conservative

knowless pin
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Hook plate
Bosworth

treatment
CC-sling

24 24
K-wire
Screw

25 Group p 25
26 Variable n=3 n=3 n=10 n=2 n=16 n=22 n=12 n=6 n=5 n=4 26
27 Constant 95,57 88,77 93,24 92,75 90,97 88,21 91,11 90,61 95,65 87,7 27
0,264
Scores ±3,46 ±10,76 ±4,37 ±0,35 ±6,14 ±5,98 ±7,32 ±4,23 ±1,76 ±12,16
28 Union 99,16 97,33 95,55 68,03 99,85 99,85 93,16 97,82 95,5 92,31
28
,003**
29 Rates ±2,22a ±4,62a ±10,01a ±8,32b ±0,65a ±0,65a ±19,79c ±4,04a ±4,47a ±18,84c 29
30 Complication 10,16 33,78 10,13 59,43 10 38,7 12,21 19,56 18,17 40,14 30
,004**
Rates ±9,02a ±42,93c ±11,09a ±28,68d ±11,81a ±47,01c ±13,74a ±19,13b ±15,38b ±38,14c
31 **p<0,01. a,b,c the values that have same superscription were not statiscally different; othervise the values that have different superscrip-
31
32 tion were statiscally different. 32
3 3
34 Results tically significant differences between the groups with 34
35 A total of ten types of treatment modalities were regards to constant scores (p= 0.301). According to 35
36 compared according to the results of constant scores, Bonferroni post hoc test, the differences were caused 36
37 union rates and complication rates. ANOVA test results by conservative treatment modalities in both union 37
38 showed significant differences between the groups with and complication rates. 38
39 respect to union rate and complication rate (p=0.000 In Regards to Pearson correlation test; there were 39
40 and p=0.000 respectively), while there were no statis- no statistically significant correlation between constant 40

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 Unstable distal clavicle fractures (Neer Type II): A Review

1 Constant's Score (The equivalence of the other scales to 1

2 Constant's score) 2
3 Higher mean Functional Scores of the Shoulder in 3
4 terms of Constant's Score were achieved using the 4
5 TBW-CC-Sling [38] (95.65), Bosworth screw 5
6 (95.57), and the CC-sling method (93.24); while low- 6
7 er constant scores were achieved using Transacromial 7
8 Figure 3. Comparison of all treatment methods according to all pa- extra-articular knowless pin (87.7), Hook plate (mean 8
rameters.
9 constant score, 88.21), and CC-sling transacromial 9
10 extra-articular Knowless pin single or double K-wire 10
11 (mean constant score, 88.77). (See the Figure 4 and 11
12 Table 1-2 ) 12
13 In regards to the constant scores; there is no difference 13
14 between the groups (See table 2, p>0,05, ANOVA test). 14
15 Complication Rates 15
16 Finally, conservative treatment had the highest 16
17 overall complication rate (59,4%), while distal clavicle 17
18 Figure 4. Constant scores of all treatment methods.
anatomic plate (10,0%) followed by CC-sling (10,13 18
19 %) had the lowest. Additional detailed results for each 19
20 scores with other scores (p=0.558, r=0.071 and p= treatment modality/study type are presented below. 20
21 0.187, r= -0.176 for union rate and complication rate (See Table 1-2, Figure 3) 21
22 respectively). However, there were statistically signifi- With regards to the complication rates, conserva- 22
23 cant correlation between union and complication rates tive treatment is found to be a statistically worst treat- 23
24 (p=0.000, r= -0.424). ment method than the others, but if we would compare 24
25 Union rates the favorite methods regarding the higher constant 25
26 The highest union rates were achieved by Distal scores , TBW –CC sling method found to be statisti- 26
27 clavicle anatomic plate (99.85%)and Bosworth screw cally worse than the CC-sling and the Bosworth screw 27
28 groups(99.1%) with Pre-contoured plate + CC sling methods. 28
29 (98.65 %), while conservative treatments had the worst Conservative Treatment [7,67,68,70] (Figure 5, Ta- 29
30 union rate (mean union rate, 68%; Figure 3, Table 2). ble 1, 2) 30
31 There were statistically significant negative correla- In this context, all data’s seems clear because the 31
32 tion between union and complication rates (p=0.000, r= authors clearly reported the complications, constant 32
33 -0.424). This result might be generated due to non-un- scores, and union rates; therefore, significant bias 33
34 ion, also referred to as a complication in our study. would not be expected. 34
35 There is only one treatment [Trans acromial know- Coracoclavicular stabilization with screw (Bosworth 35
36 less pin /K-wires or IM (extra-articular) Knowles pin] technique; Figure 6, Table 1, 2) [7,10,38,51,60,66,76] 36
37 statistically worse than the other surgical treatments, Regarding to complications, displacement of the 37
38 the conservative treatment method was found to be fracture due to screw loosening, nonunion, backing 38
39 statistically different (worse) than all other methods. out of screws, and deltoid wasting were reported. An- 39
40 Mean Functional Scores of the Shoulder in terms of dersen et al. [13] performed a study in which he per- 40

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Figure 6. IIlustration of the Bosworth screw technique.
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17 Figure 5. Illustration of conservative management. 17
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19 formed mainly two groups of Pre-contoured plate+CC 19
20 sling and distal clavicle anatomic plate, he added two 20
21 patients who were treated with distal clavicle anatom- 21
22 ic plate combined with CC screw (Bosworth screw), 22
23 these two patients were not included in this context to 23
24 avoid bias. 24
25 Additionally, regarding to the evaluation of the 25
26 constant scores, Edward [7], Yamagushi [10] ,Balmerr 26
27 [51], Fazal [60], Macheras [66] and Jin [76] et al. did 27
28 not report their own functional results with constant Figure 7. Illustration of the CC-sling method. 28
29 score. However, we equalize the values which we de- 29
30 scribed in the methods section. their own functional scores quantitatively. However, 30
31 Coracoclavicular Sling [18,22,40,48,50,52,61,67,85, we equalize the values which we described in the meth- 31
32 90,92,97,98,99] (Figure 7, Table 1, 2) ods section. Those studies would generate a weak bias 32
33 Reported complications included clavicular ero- regarding the calculation of the accurate mean constant 33
34 sion, asymptomatic fibrous nonunion, delayed union, functional scores of the shoulder, but this would not 34
35 nonunion, malunion, frozen shoulder, skin irritation, frustrate the general assessment. 35
36 low grade infection, metal work failure (titanium ca- TBW with / without K-wire [8,9,24,36,37,42,64,91] 36
37 ble), and deep infection. In this group Li Y and Mall JW (Figure 8, Table 1, 2) 37
38 et al. [40,61] reported the functional scores with dif- Regarding to complications, wire migration, tech- 38
39 ferent scoring systems rather than Constant, UCLA or nical difficulties, soft tissue issues, loosening and break- 39
40 ASES scores. Goldberg JA, et al [48] hasn’t expressed down of the wires, heterotopic ossification, cerclage 40

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13 Figure 8. IIlustration of the TBW with a parallel K-wire method. 13
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15 wire disruption, infection, reduction loss, and non- 15
16 union were reported. In this group, Kao FC et al. did 16
17 not express their own functional scores quantitatively. 17
18 However, they stated that all cases gained full ROM of 18
19 the shoulder. This study would generate a weak bias 19
20 with regards to calculating the accurate mean constant 20
21 of functional scores of the shoulder, but this would not 21
22 frustrate the general assessment. 22
23 Transacromial Knowles/K-wires or intramedullary 23
24 (extra-articular) Knowles pin [7,31,32,37,63,105] (Fig- 24
Figure 9. Illustration of the transacromial Knowles pin and single
25 ure 9, Table 1, 2) k-wire fixation method. 25
26 Regarding complications, K-wire migrations, skin 26
27 irritations, and potential K-wire breakage were reported. while 8 patients were non-union with late consults. We 27
28 Hook plate [9,18,20,23,25,29,30,36,39,46,47,53,57,6 could not accurately divide those patients for final cal- 28
29 4,65,69,71,75,84,85,87,90,94 - 96] (Figure 10, Table 1, 2) culation of the mean Constant scores. Therefore, these 29
30 Regarding to complications; impingement symp- studies would generate a weak bias to calculate accurate- 30
31 toms, osteolysis of the undersurface of the acromion, ly the mean constant functional scores of the shoulder, 31
32 rotator cuff ruptures, acromion fractures, and shoulder but this would not frustrate the general assessment. 32
33 pain were reported in this group. Distal clavicle anatomic plate fixation methods 33
34 In this group Kashii M [30], Mizue F [71] and [19,20,25,26,41,44,45,58,59,77,79,86,96,100-103] 34
35 Flinkkilä T [65] et al. reported the functional scores (precontoured plate, LCP, distal radius volar plate, 35
36 with different scoring systems rather than Constant, T-plate; Figure 11, Table 1, 2) 36
37 UCLA or ASES scores. However, we equalize the val- The reported complications are; AC-joint screw 37
38 ues which we described in the methods section. penetration, superficial infection, complaints regarding 38
39 Meda PV et al. [75] reported 31 patients with which discomfort due to the plate, and post-operative hemat- 39
40 they operated 23 patients to have had acute injuries, oma were reported. In this group majority of the cas- 40

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Figure 10. IIlustration of the hook plate fixation method.
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Figure 12. Illustration of the TBWplus CC-sling fixation and distal
25 clavicle anatomic plate plus CC-sling fixation method. 25
26 Figure 11. Illustration of the distal anatomic plate fixation method. 26
27 to excellent functionality about the shoulder. These 27
28 es were evaluated with constant (n=13),ASES (n=1), studies would generate a weak bias regarding the ac- 28
29 UCLA (n=1) and Oxford (n=1) scoring system, only curate calculation of the mean constant functional 29
30 Abdelhayam A et al. reported the functional results scores of theshoulder, without frustrating the gener- 30
31 with a modified shoulder score. One study did not al assessment. 31
32 report any score. However, we equalize the values de- Pre-contoured plate + CC sling [11,13,15,16,23,59,77, 32
33 scribed in the methods section. 80,81,84,87,100,104] (Figure 12, Table 1, 2) 33
34 That would generate a weak bias regarding the In this group majority of the cases were evaluat- 34
35 evaluation of the mean functional scores ofthe shoul- ed with constant (n=7), and ASES(3) scoring system, 35
36 der, but this would notfrustrate the general assessment. Only Hessmann M et al. (n=2) [59] did not express 36
37 TBW-CC-Sling [35,59,80,82,88] (Figure 12, Table 1, 2) their own functional scores quantitatively. However, 37
38 In this group, Chen CH [88] and Hessmann they reported goodto excellent functionality about the 38
39 M et al. [59] did not express their own functional shoulder. These studies would generate a weak bias re- 39
40 scores quantitatively. However, they reported good- garding the accurate calculation of the mean constant 40

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 Unstable distal clavicle fractures (Neer Type II): A Review

1 Exotic and Unusual methods [49,55] 1

2 Several exotic fixation methods were reported. The 2
3 small amount of cases were enrolled in those studies, so 3
4 these studies were excluded in the general assessment 4
5 of the methods. 5
6 Discussion 6
7 We performed a systematic review of the availa- 7
8 ble methods for unstable distal clavicle fractures (Neer 8
9 Type II). The results are conflicting, if data’s is evaluat- 9
10 ed from the functional scores. Bosworth screw (95.57), 10
11 TBW-CC-Sling [38] (95.65), and the CC-sling (93.24) 11
Figure 13. Illustration of the single k-wire /transacromial Knowles pin
12 combined with CC-sling fixation method.
methods seem to better than the others (with regards to 12
13 functional scores). However, if the complication scores 13
14 functional scores of theshoulder, but this would not is closely examine, it would be easy to figure out neg- 14
15 frustrate the general assessment. atively high complication rates of Conservative treat- 15
16 CC- sling+transacromial extra-articularKnowless pin/ ment and Transacromial extraarticular knowless pin 16
17 single or double K-wire [28,62,79] (Figure 13, Table 1, 2) method (59.4% and 40.1% respectively). From this 17
18 It is worth noting, that two of these studies de- point of view, one can easily concludes that Bosworth 18
19 scribed new surgical techniques [59,75]. screw, CC-sling methods and Pre-contoured plate+CC 19
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39 Figure 14. According to the Error Bar Graphs ,the wide range (53%-100%) of transacromial extra-articular knowlesspin union rates is worrying
39
40 about the reliability of this technique. 40

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19 Figure 15. According to the Error Bar Graphs ,the results of Bosworth Constant scores was not reliable enough (range 32-98).
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21 sling, have both low complication rates with high con- shows lower complication rates, while the union rate is 21
22 stant scores. (See Figure 14, Table 2). not promising. 22
23 With regards to union rates, CC-sling method The reliability of the mean constant scores has been 23
24 seems to have lower results than distal anatomic plate assessed with the error bar graphs. According to the er- 24
25 and pre-contoured plate + CC-sling. Thus, distal clavi- ror bar graphs the results of Bosworth technique was 25
26 cle anatomic plate and pre-contoured plate + CC-sling found to be less reliable than the others. (See Figure 15) 26
27 methods seems to have relatively better scores than the Complication rates 27
28 others. In addition, these methods offer very high un- Although the conservative treatment is considered 28
29 ion rates compared to the majority of the other meth- as an alternative to surgery, it has the unfortunate dis- 29
30 ods.(See Figure 14 , Table 2) advantages of a higher complication rate and a lower 30
31 The reliability of the mean union rates have been as- union rate. 31
32 sessed with an error bar graph. According to the error bar The reliability of the mean complication rates has 32
33 graphs, the wide range (53 %- 100%) of Transacromial been assessed with the error bar graphs. 33
34 extra-articular knowles pin union rates is worrying about The error bar graphs shows that, the majority of 34
35 the reliability of this technique. (See Figure 14, Table 2) all the treatment modalities has a wide range of com- 35
36 A constant score of the distal clavicle anatomic plication rates except the distal clavicle anatomic plate, 36
37 plate group is also moderately high (90.9). Finally, both precontoured plate + CC-sling and CC-sling methods. 37
38 plate group seem to have relatively better functional (See Figure 16) 38
39 scores with union rates, while the complication rates Plating is another widely used alternative and new 39
40 are lower than the other methods. CC-sling method implants are being developed for holding the distal 40

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 Unstable distal clavicle fractures (Neer Type II): A Review

1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 Figure 16. The error bar graphs showed that, the majority of the all treatment modalities have a wide range of complication rates (ranges: 8%- 19
83.3 % , 30%-95%, 3.1%- 170% , 0%- 59.1% , 7%-50%, 3%-84% ) for CCsling, conservative treatment, hook plate, TBW with or without K wire,
20 TBW CC sling, Transacromial extraarticular knowless-pin techniques respectively. 20
21 21
22 small part of the fractures with multiple small locking in the mid-substance to avoid coracoid fractures. A rule 22
23 screwholes. These implants do not cross the AC joint of thumb in screw purchase is that the screw should 23
24 or hinder the rotational clavicular movement at the cross the coracoid cortex in order to achieve compres- 24
25 AC, thereby making implant removal unnecessary. In sion and reduction. This requires particular attention so 25
26 addition, this technique has a unique advantage in that as not to damage the surrounding neurovascular struc- 26
27 it does not seem to have the necessary CC ligament tures. Moreover, early rehabilitation of the shoulder in- 27
28 substitution. Also, the reported complications were cluding shoulder abduction should be avoided as this 28
29 not severe. In this study distal anatomic clavicular plate fixation method blocks the physiologic rotation of the 29
30 shows promising results. clavicle over the acromion during shoulder abductions 30
31 CC substitution in the form of a CC-Sling has the over 90°. We know that this method restricts the clav- 31
32 advantage of replacing CC ligaments, which serve as a icular movement during the shoulder abduction above 32
33 neutralizing force against the dead-weight of the arm 90°, therefore surgeon’s should remove the screw when 33
34 and pulling effect of trapezius muscle. Its disadvantages the bony union is achieved. In addition, complication 34
35 include exposure to the coracoid, which requires exten- rate of this method is not ideally low (10.16 %), despite 35
36 sive dissection, technical difficulties during sling appli- all of these disadvantages, the reported functional out- 36
37 cation, and the risk of injury to the neurovascular struc- come scores were very satisfactory. 37
38 tures along the medial side. The CC screw, method also The transacromial Knowles/K-Wires or intramed- 38
39 has similar disadvantages, including difficulties in screw ullary (extra-articular) Knowles pin and TBW with 39
40 placement in the coracoid, as it must be placed directly K-wire application techniques is relatively easy to per- 40

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 Gokkus K et al.

1 form and does not require extensive soft tissue strip- In the present study, Bosworth screw method, CC- 1
2 ping. Unfortunately, these methods also have a relative- sling, distal anatomic plate method appeared to have 2
3 ly higher complication rate compared to that of other the lowest complication rate among all evaluated tech- 3
4 methods (See table 2). In addition, hardware-related niques. (See the Figure 3, Table 2) 4
5 problems were also reported, which is usually caused Reviews [12,34,43,74,106] 5
6 by the shape of the Knowles pin. Only four reviews were found in the literature 6
7 TBW, with or without the K-wire method, shows a search. The results of all groups were not parallel and 7
8 relatively higher union rate than the other surgical tech- some of them concluded the opposite results. None 8
9 niques. Unfortunately, this method also has a relatively of them consisting with large number of articles com- 9
10 higher complication rate compared to the other meth- paring to our study. Two years ago, one significant sys- 10
11 ods and came in fifth, after CC-Sling - Single K-wire tematic review with network meta-analysis has been 11
12 or Knowles pin method. On the other hand, a tension performed by Boonard M et al. Five classes of fixation 12
13 band wiring technique is a unique technique, which is methods have been evaluated: coracoclavicular fixa- 13
14 moderately difficult for young surgeons; hence, sur- tion, hook plating, plate and screws, tension band wir- 14
15 geon’s should be familiar with the tricks of this method. ing and trans-acromial Knowles pin fixation. According 15
16 Abduction movement of the shoulder joint to their study, the most effective approach for higher 16
17 (above 90°) requires clavicle rotation within the AC Constant and UCLA scores was CC fixation and plate 17
18 joint. For this reason, treatment techniques which and screw fixation. In terms of complications, they 18
19 block this physiological rotation (especially hook founded that the plate and screw fixation has the first 19
20 plate and transacromial fixation methods, Bosworth better rank, while the parallel with us they found that 20
21 screw) would delay shoulder rehabilitation, including Transacromial Knowles pinning had the worst rank out 21
22 abduction above the head. The hook plate has a small of the 5 fixation methods. 22
23 hook that hinges the acromion to aid reduction [74]. Biomechanic cadaver study [107] 23
24 This feature makes the hook plate method prone to Yagnik GP et al. [107] performed a biomechanic 24
25 generic impingement symptoms, osteolysis of the study on cadavers in 2019, they established four distinct 25
26 undersurface of the acromion, rotator cuff ruptures, groups to compare : (1) distal-third locking plate (P); 26
27 acromion fractures, and shoulder pain. Another ma- (2) distal-third locking plate with a coracoid button 27
28 jor concern is the requirement of a second surgery for augmentation (P + CB); (3) coracoclavicular button 28
29 removal [74]. Finally; the present study demonstrat- (CB); and (4) coracoclavicular button with coracocla- 29
30 ed that this method has the 3rd highest complication vicular ligament reconstruction using semitendinosus 30
31 rate. (Table 2) allograft (CB + CC). All 3 experimental groups biome- 31
32 Complications from the simple to complex were chanically demonstrated better values than the locking 32
33 included in this study. Conservative treatment, hook plate. But they also emphasized that addition of CC- 33
34 plate fixation, Transacromial Knowles/K-wires, and sling on to the distal clavicle anatomic plate enhances 34
35 the CC-sling-single K-wire or Knowles fixation method the biomechanical performance of the plate. 35
36 appeared to have higher complication rates. Although Limitations 36
37 TBW + CC sling methods were reported to have better Functional outcomes could not be compared thor- 37
38 functional results, their complication rates were higher oughly in this study due to the employment of various 38
39 than those for distal anatomic plate and precontoured assessment scales. The strength of all mean functional 39
40 plate + CC sling treatment method. score results are not equal in this study, because the var- 40

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 Unstable distal clavicle fractures (Neer Type II): A Review

1 ious functional scoring systems were utilized in various 2. Neer CS 2nd. Non-union of the clavicle. J Am Med 1
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37 © 2020 Turkish Society for Surgery of the Hand and Upper Exremity. This is an open access article licensed under the terms of the Creative Commons Attribution
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38 NonCommercial ShareAlike 4.0 (https://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, noncommercial use, distribution and reproduction
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 Unstable distal clavicle fractures (Neer Type II): A Review

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