Displaced Midshaft Clavicle Fractures: Non-operative! J. Martin - - PowerPoint PPT Presentation

DrMartinLeland

Displaced Midshaft Clavicle Fractures: Non-operative!

• J. Martin Leland, M.D.

@DrMartinLeland

Orthopaedic Sports Surgeon & Medical Director of Sports Medicine University Hospitals Geauga Medical Center, Cleveland, OH Associate Editor, Arthroscopy Journal Board of Directors, Arthroscopy Association of North America

DrMartinLeland

Disclosure

• J. Martin Leland III, MD

The following conflicts exist:

1.

Consulting: ConMed

2.

Editorial Board: Arthroscopy Journal

3.

Board of Directors: AANA

4.

I treat displaced, midshaft clavicle fractures with ORIF

5.

I have the highest respect for Dr. McKee &

• Dr. Basmania

DrMartinLeland

Poll the Audience

Raise your hand if you have been

forced to treat a displaced, midshaft clavicle fracture non-

• peratively.

DrMartinLeland

Rate of Non-Union for Non-op

J Orthop Trauma. 2005

Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group.

• McKee et al.

 Nonop treatment of 1145 fractures  94% healed!  Looking at displaced fractures separately (159 fx)

 85% healed!

DrMartinLeland

What If It DOESN’T Heal??

J Shoulder Elbow Surg. 2007

Does delay matter? Immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle

• McKee et al.

 Acute group (15): ORIF with plate @ 2 wks post-injury  Delayed group (15): ORIF, bone graft, plate @ 5 yrs

DrMartinLeland

What If It DOESN’T Heal??

J Shoulder Elbow Surg. 2007

Does delay matter? Immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle

• McKee et al.

 Both groups rated their satisfaction with the procedure as

excellent

 No difference with regards to: strength of shoulder,

DASH scores

 Acute group had mildly better: Constant score (95 vs 89)

and shoulder endurance

DrMartinLeland

What Are Risks of Surgery?

• 1. Infection
• 2. Neurovascular injury
• 3. Need for additional surgery

DrMartinLeland

Reoperation Following ORIF

J Orthop Trauma. 2015

Prognostic Factors for Reoperation After Plate Fixation of the Midshaft Clavicle -McKee et al.

 Single university tertiary care Level 1 trauma center  Complete follow-up on 153 of 235 consecutive patients

 Reoperation rate = 40%!!! (58 of 153 patients)  Complex or Multiple procedures in 10%!!! (16 of

153 patients)

DrMartinLeland

What about Healthcare COSTS!?!

Non-operative costs Operative costs

Is that Dr. McKee???

DrMartinLeland

From McKee’s Own Mouth…

JBJS 2013

Commentary & Perspective by Dr. McKee

Commentary on an article by C.M. Robinson et al.: ‘‘Open Reduction and Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular

• Fractures. A Multicenter, Randomized, Controlled Trial’’

 “Most patients with a displaced midshaft clavicle fracture

will respond relatively well to nonoperative care, and the ‘‘number needed to treat’’ to avoid a specific negative

• utcome, such as nonunion, is high. For example, this study

calculated that it would be necessary to treat SEVEN fractures with primary plate fixation in order to prevent ONE nonunion.”

DrMartinLeland

Monday Morning….

 First 7 patients of the day all have displaced,

midshaft clavicle fractures!

 Option 1:

– Operate on all 7 (Your time and healthcare’s $$$$) – Reoperate on 2 of 7 for plate removals – Reoperate on 1 of 7 for “complex additional

procedures”

 Option 2:

– Treat all 7 non-operatively – In 3-6 months: Bone graft and plate the 1 non-union

DrMartinLeland

Thank You!

: DrMartinLeland

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