The comparison of Nice knots and traditional methods as an auxiliary reduction-fixation technique in pre-contoured locking plate fixation for comminuted Robinson type 2B clavicle fracture: A retrospective study

Abstract

Open reduction and pre-contoured locking plate fixation is a popular treatment option for displaced midshaft clavicle fracture. Lag screw and cerclage are 2 main intraoperative techniques to reduce and fix fragments. However, both lag screw and metallic cerclage have disadvantages. The doubled-suture Nice knot has been reported in many areas of orthopedic surgery for its effectiveness. This study aims to compare the outcomes of comminuted mid-shaft clavicle fractures reduced by Nice knots vs traditional techniques (lag screw or/and metallic cerclage) when bridged with pre-contoured locking plates.We retrospectively reviewed 101 patients (65 females and 36 males) diagnosed with midshaft clavicle fractures with at least one wedge fragment reduced by either Nice knots or traditional methods and bridged with pre-contoured locking plates between December 2016 and April 2019. Operation time, functional outcomes, pain, patient satisfaction, fracture healing, and complications were assessed at a follow-up of 12 to 40 months.The mean age of all the patients was 50.8 years. There were 52 and 49 patients in the Nice knot group and traditional group respectively, and no differences between 2 groups were found in general patient characteristics, fracture type, follow up and injury-to-surgery duration. The Nice knot group had significant less operation time (P < .01) than the traditional group (mean and standard deviation [SD], 78.6 ± 19.0 compared with 94.4 ± 29.9 minutes, respectively). For healing time, functional score, pain, satisfaction and complications, there were no significant differences between groups, despite the Nice knot group had slightly better results.Both Nice knots and traditional methods treated for comminuted Robinson type 2B clavicle fractures were effective and safe. And the Nice knots seemed to be superior with significant less operation time.

Figure 1

Flow chart of patients screening.

Figure 2

The key steps of the Nice knot introduced by needle tail (demonstrated with a 3D model of clavicle and No. 5 Ethibond). (A) Needle tail through the tissue around model. (B–D) Draw out the suture and then return the needle to get a doubled-over suture. (E) Make a Nice knot with single free limb passing through the loop. (F) The knot is slid down by pulling the 2 free limbs apart.

Figure 3

A 34 years old male patient with Type 2B2 left clavicle fracture in the Nice knot group. (A) Preoperative CT scan. (B) Postoperative X-ray. (C) X-ray after removal of implant at 14 months. (D) The prereduced fracture and doubled-over suture induced by needle tail. (E) Reduction and temporarily fixation of the fracture by 2 Nice knots. (F) Bridged with a precontoured locking plate and screws.

Figure 4

The 49 years old male patient with plate breakage in the Nice knot group. (A) Preoperative CT scan. (B) Postoperative X-ray of primary surgery. (C) Plate rupture occurred 7 months after surgery. (D) Postoperative X-ray of revision surgery using combination of anatomic and mini plate with auto cancellous bone graft. (E and F) X-ray of 6 and 16 months follow up after revision surgery.

Figure 5

The nonunion and refracture cases in the traditional group. (A–D) X-ray of preoperation, postoperation, postremoval and refracture 2 months after removal for the 21 years old female patient. (E–H) X-ray of preoperation, postoperation, second injury at 12 months and last follow-up at 23 months for the 20 years old male patient.