The challenge of nonunion after osteosynthesis of the clavicle: is it a biomechanical or infection problem?

Q3 Medicine Clinical Cases in Mineral and Bone Metabolism Pub Date : 2017-09-01 Epub Date: 2017-12-27 DOI:10.11138/ccmbm/2017.14.3.372
Giuseppe Rollo, Paolo Pichierri, Antonio Marsilio, Marco Filipponi, Michele Bisaccia, Luigi Meccariello
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引用次数: 27

Abstract

Introduction: The nonunion rate has been reported between 0.1% and 15%. There are also several predisposing factors for the onset of complications: general factors connected with the patient and specific factors related to the fracture site. The purpose of our study is to review the etiology of nonunion of the clavicle in its atrophic form and investigate the outcomes of the revision treatment in a single step.

Materials and methods: Retrospective study on 71 patients suffering from nonunions due to the following treatments: conservative in 13 patients; plate fixation in 12; closed reduction and fixation with K-wire in 24; open reduction and fixation with K-wire. All patients were operated on in beach chair position and classic approach to the clavicle by incising the previous surgical scar. The clinical and radiographic criteria for evaluating the outcomes were: the Short Form (12) Health Survey (SF-12), the Constant Shoulder Score (CSS) and the Disability Disabilities of the Arm, Shoulder and Score (DASH) and radiographic Union Score (RUS) for bone healing. The evaluation endpoint was set at 12 months.

Results: Blood and culture tests showed 22 infected nonunions and 49 atrophic or oligoatrophic. In only 10 cases, before surgery, the inflammatory markers were positive. The isolated microorganisms were resistant to common antibiotics. In 70 out of 71 cases, plates and screws on the upper side and fibula allogenic splints at the bottom, associated with cancellous bone grafts taken from the patients' iliac crests, were implanted. In one case, however, it was decided to implant the plate on the front edge of the clavicle and the fibula allogeneic splint on the posterior margin, also associated with a cancellous bone graft taken from the patient's iliac crest. The radiographic bone healing was observed in 107.8 (range 82-160) days for the aseptic nonunions, while in 118.4 (range 82-203) days for the septic ones. The non-healing case was a serious failure that led to asubtotal excision of the clavicle.

Conclusions: The importance of classification and study of nonunions are essential to achieve positive outcomes. The guiding principle of our work is that aseptic nonunions heal in the operating room, while infected nonunions can be challenged and defeated on the operating table. Restoring the correct length of the clavicle interconnection between the sternum and the shoulder cingulum is indispensable to avoid functional deficits of the upper limb. The fibula splint and the tricorticale bone graft have both mechanical and strong biological values to quickly heal the nonunion. The return to pre-injury quality of life has to be our main goal.

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锁骨骨融合术后骨不连的挑战:是生物力学问题还是感染问题?
导读:据报道,骨不愈合率在0.1%至15%之间。并发症的发生也有几个易感因素:与患者有关的一般因素和与骨折部位有关的特殊因素。我们研究的目的是回顾锁骨萎缩不连的病因,并探讨一次翻修治疗的结果。材料与方法:对71例经保守治疗的骨不连患者进行回顾性分析:保守治疗13例;钢板固定在12;k针闭合复位固定24;切开复位并用k针固定。所有患者均采用沙滩椅位和经典的锁骨入路,通过切开先前的手术疤痕。评估结果的临床和放射学标准为:简短(12)健康调查(SF-12)、肩部恒定评分(CSS)和手臂、肩部残疾及评分(DASH)以及骨愈合的放射学联合评分(RUS)。评估终点设定为12个月。结果:血液和培养检查显示22例感染不连,49例萎缩或少萎缩。只有10例患者在手术前炎症标志物呈阳性。所分离的微生物对常用抗生素具有耐药性。在71例患者中,有70例患者在上侧植入钢板和螺钉,在下端植入腓骨同种异体夹板,并从患者髂骨嵴取下松质骨移植物。然而,在一个病例中,我们决定在锁骨前缘植入钢板,在锁骨后缘植入腓骨异体夹板,同时从患者的髂骨上取下松质骨移植物。无菌性骨不连的x线骨愈合时间为107.8天(82-160天),而感染性骨不连的x线骨愈合时间为118.4天(82-203天)。未愈合的病例是一个严重的失败,导致锁骨几乎全部切除。结论:对骨不连进行分类和研究对于取得积极的治疗效果至关重要。我们工作的指导原则是无菌性骨不连在手术室中愈合,而感染性骨不连可以在手术台上被挑战和击败。恢复胸骨与肩带之间锁骨连接的正确长度对于避免上肢的功能缺陷是必不可少的。腓骨夹板和三皮质骨移植物具有快速愈合骨不连的力学和生物学价值。恢复到受伤前的生活质量是我们的主要目标。
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Clinical Cases in Mineral and Bone Metabolism
Clinical Cases in Mineral and Bone Metabolism ENDOCRINOLOGY & METABOLISM-
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期刊介绍: The Journal encourages the submission of case reports and clinical vignettes that provide new and exciting insights into the pathophysiology and characteristics of disorders related to skeletal function and mineral metabolism and/or highlight pratical diagnostic and /or therapeutic considerations.
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