Additional bone graft accelerates healing of clavicle non-unions and improves long-term results after 8.9 years: a retrospective study

Abstract

Background: Clavicle non-unions can occur after both conservative and operative treatment failure. Here, we investigated the outcome of patients with delayed fracture healing or non-unions of the clavicle. Patients underwent revision surgery by plate osteosynthesis of the clavicle with or without bone grafting. Our aim was to determine rates of bone healing and the functional long-term outcome.

Methods: The study population of 58 consecutive patients was divided into group 1 (n = 25; no bone graft) and group 2 (n = 33; iliac crest bone graft). Bone consolidation was determined by the Lane-Sandhu score preoperatively and after 2.2 ± 1.8 years, respectively. The functional long-term outcome was determined after 8.9 ± 2.7 years in all available patients (n = 30) by the Constant score, DASH (Disabilities of the Arm, Shoulder and Hand) score and SF-36, and clavicle length was measured by ultrasound as compared to the healthy side.

Results: Clavicle consolidation was achieved in 54 out of 58 patients (93.1%) after revision surgeries. The radiographic score and bone consolidation rates were significantly higher in group 2 (93.3%) as compared with 72% in group 1 (p = 0.02), resulting in a significantly shorter time to bone consolidation in group 2. Similarly, the relative risk for additional surgery after the first revision surgery was 4.7-fold higher in group 1 (p = 0.02). The long-term results showed overall very good results in DASH score (14.9 ± 16.5) and good results in Constant scores (77.9 ± 19.9). The group analyses found significantly better Constant scores and better visual analogue pain scale (VAS) numbers in group 2. Clavicle shortening appeared to affect the clinical results, and a mild correlation between shortening and Constant scores (R = -0.31) was found.

Conclusions: This study shows high rates of bone healing and good functional outcomes after surgical revision of clavicle non-unions and further demonstrates that additional bone graft could significantly accelerate bone healing. This indicates that revision surgery of clavicle non-unions might preferably be done with additional bone graft, even if the surgeon considers that bone healing might be achieved without bone grafting.

Figure 1

Study population with variation of the included types of fracture healing complication.

Figure 2

Flowchart with an overview of patient selection and treatment groups.

Figure 3

Distribution of implant types during revision surgery.

Figure 4

Results of the Constant score after 8.9 ± 2.7 years, with variation of treatment groups; p  = 0.04.

Figure 5

Correlation between shortening of the clavicle and Constant score, irrespective of the treatment group.

Figure 6

Non-union (right-sided, R) 6 months after fixation with a titanium elastic nail in a 43-year-old male with mechanical instability (a-c). (b) Result after revision with distant bone graft, length correction and LCP fixation. (c) Bone consolidation after metal removal.