Risk factors for complications and reoperation following operative management of displaced midshaft clavicle fractures

Abstract

Background: Optimal management of a displaced midshaft clavicle fracture remains controversial. This study assessed demographic factors, fracture pattern, and surgical technique as potential predictors of surgical complications. Smoking, diabetes, obesity, polytrauma, high-energy mechanism, inpatient status, transverse or comminuted fractures, and single-plating technique were hypothesized to be associated with an increased risk of complications following clavicle fracture open reduction internal fixation (ORIF).

Methods: Consecutive patients with minimum 12-week follow-up from the trauma and sports medicine divisions at a single tertiary institution who presented with a midshaft clavicle fracture and underwent ORIF between 2007 and 2020 were retrospectively identified. Patient demographics, fracture pattern, plating technique, and postoperative complications were recorded. Postoperative complications were classified into major (reoperation) and minor (no reoperation) complications. Chi-squared statistics, Fisher's exact test, analysis of variance, Kruskal-Wallis test, and multivariate logistic regression modeling were utilized with a significance level set to P < .05.

Results: One hundred ninety-eight patients (average = 39.5 ± 14.6 years) were identified with an average follow-up of 9.1 ± 10.7 months. The cohort consisted of 155 males (78.3%), 62 smokers (31.3%), and 12 diabetics (6.1%). Injury characteristics revealed 80 transverse fractures (40.4%), 87 oblique fractures (43.9%), and 31 Z-type fractures (15.7%). Seventy-nine patients (39.9%) underwent superior plating, 72 (36.4%) underwent anterior plating, and 47 (23.7%) underwent dual plating. Overall, postoperative complications occurred in 47 patients (23.7%), 29 minor (14.6%) and 18 major (9.1%). Major complications requiring reoperation were symptomatic hardware, nonunion, deep infection, wound dehiscence, and broken hardware. Minor complications consisted of sensory deficit or paresthesia beyond peri-incisional numbness, superficial infections, postoperative pain and/or stiffness, and delayed union. Smoking status (P = .008), obesity (P = .009), and transverse or Z-type fractures (P = .002) were significant prognostic factors for overall complication risk. Only manual labor was predictive of minor complications (P = .019). Transverse or Z-type fractures and single plating were predictive of major complications (P = .004 and P = .008, respectively). No reoperations occurred in patients who underwent dual plating. Smokers (P = .027) with transverse/Z-type fractures (P = .022) were at the highest risk of reoperation with single plating.

Conclusion: The overall rate of complications following ORIF of displaced midshaft clavicle fracture was 27.3%, with 9.1% requiring reoperation. Given relatively high complication rates, in instances when nonoperative vs. operative management is equivocal, nonoperative management should be strongly considered in obese patients, smokers, and patients who present with transverse or Z-type fracture. If operative management is indicated, use of dual plating may decrease reoperation rates.

Keywords: Midshaft clavicle fracture; dual vs. single plating; open reduction and internal fixation (ORIF); postoperative complications; reoperation; trauma.