A meta-analysis of the necessity of coracoclavicular ligament reconstruction in the treatment of unstable distal clavicular fractures with locking plate_West China Medical Journal

Authors：

WANG Tao ^1,2 , LOU Yuanyi ² , CHEN Zhoutao ² , HUANG Yongbin ² , LI Liwei ² , HUANG Chunman ² , PANG Jingqun ² ,  CHEN Guanghua ²

1. Orthopaedic Center, the Sixth People’s Hospital of Huizhou, Huizhou, Guangdong 516211, P. R. China;
2. Department of Orthopaedics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong 524000, P. R. China;

Corresponding?author：

CHEN Guanghua, Email: 404654885@qq.com

Keywords：

Distal clavicular fracture; coracoclavicular ligament reconstruction; locking plate

DOI：

10.7507/1002-0179.202301035

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Objective To investigate the necessity of coracoclavicular ligament reconstruction in the treatment of unstable distal clavicular fracture with locking plate. Methods We searched PubMed, the Cochrane Library, Embase, China National Knowledge Infrastructure, Wanfang database and VIP database for all the articles about the treatment of unstable distal clavicular fractures using locking plate combined with coracoclavicular ligament reconstruction or locking plate alone from the establishment of databases to November 30th, 2022. According to the inclusion and exclusion criteria, we selected the documents that met the requirements of this paper, and extracted the effective data after evaluating the quality of the documents, including the Constant-Murley score, coracoclavicular distance, fracture healing time, complication rate, operative time, intraoperative blood loss, incision length and the Visual Analogue Scale score of postoperative pain. RevMan 5.4 software was used for meta-analysis. Results A total of 11 retrospective cohort studies were included, and the overall quality of the literature was high. A total of 421 cases were included in this study, including 209 cases in the locking plate combined with coracoclavicular ligament reconstruction group and 212 cases in the locking plate group. The results of meta-analysis showed that locking plate combined with coracoclavicular ligament reconstruction in the treatment of unstable distal clavicular fractures was superior to locking plate alone in the Constant-Murley score [mean difference (MD)=7.35, 95% confidence interval (CI) (2.84, 11.87), P=0.001], coracoclavicular distance [MD=–1.22 mm, 95%CI (–1.92, –0.53) mm, P=0.0006], fracture healing time [MD=–2.76 weeks, 95%CI (–4.74, –0.79) weeks, P=0.006] and complication rate [odds ratio=0.31, 95%CI (0.14, 0.68), P=0.004], but the former had longer operative time [MD=9.27 min, 95%CI (4.53, 14.01) min, P=0.0001]. There was no significant difference in the intraoperative blood loss [MD=3.31 mL, 95%CI (–17.01, 23.63) mL, P=0.75], incision length [MD=0.30 cm, 95%CI (–0.11, 0.71) cm, P=0.15], or Visual Analogue Scale score of postoperative pain [MD=–0.26, 95%CI (–0.79, 0.27), P=0.33]. Conclusions Although the reconstruction of the coracoclavicular ligament increases the time of surgery, locking plate combined with coracoclavicular ligament reconstruction in the treatment of unstable distal clavicular fractures is significantly better than locking plate alone in terms of reduction quality, shoulder function recovery, fracture healing time, and the incidence of complications, without significant intraoperative bleeding, prolonged incision or postoperative pain.

Citation： WANG Tao, LOU Yuanyi, CHEN Zhoutao, HUANG Yongbin, LI Liwei, HUANG Chunman, PANG Jingqun, CHEN Guanghua. A meta-analysis of the necessity of coracoclavicular ligament reconstruction in the treatment of unstable distal clavicular fractures with locking plate. West China Medical Journal, 2023, 38(6): 892-900. doi: 10.7507/1002-0179.202301035 Copy

1.	Sandstrom CK, Gross JA, Kennedy SA. Distal clavicle fracture radiography and treatment: a pictorial essay. Emerg Radiol, 2018, 25(3): 311-319.
2.	NEER CS 2nd. Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma, 1963, 3: 99-110.
3.	Neer CS 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res, 1968, 58: 43-50.
4.	Hall JA, Schemitsch CE, Vicente MR, et al. Operative versus nonoperative treatment of acute displaced distal clavicle fractures: a multicenter randomized controlled trial. J Orthop Trauma, 2021, 35(12): 660-666.
5.	韋永安, 周繼輝, 陳文瑤, 等. 鎖骨遠端骨折治療及內置物的選擇. 中國組織工程研究, 2021, 25(30): 4877-4882.
6.	Shin SJ, Ko YW, Lee J, et al. Use of plate fixation without coracoclavicular ligament augmentation for unstable distal clavicle fractures. J Shoulder Elbow Surg, 2016, 25(6): 942-948.
7.	Kapicioglu M, Erden T, Bilgin E, et al. All arthroscopic coracoclavicular button fixation is efficient for Neer type II distal clavicle fractures. Knee Surg Sports Traumatol Arthrosc, 2021, 29(7): 2064-2069.
8.	Robinson PG, Williamson TR, Yapp LZ, et al. Functional outcomes and complications following combined locking plate and tunneled suspensory device fixation of lateral-end clavicle nonunions. J Shoulder Elbow Surg, 2021, 30(11): 2570-2576.
9.	Xie Z, Song M, Zhou J, et al. Precontoured locking compression plate with titanium alloy cable system: in treatment of neer type IIb distal clavicle fracture. Orthop Surg, 2021, 13(2): 451-457.
10.	Han L, Hu Y, Quan R, et al. Treatment of Neer IIb distal clavicle fractures using anatomical locked plate fixation with coracoclavicular ligament augmentation. J Hand Surg Am, 2017, 42(12): 1036.e1-1036.e6.
11.	Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9): 603-605.
12.	馬昌科, 沈憶新, 陽利武. 單純解剖鎖定鋼板內固定與聯合喙鎖韌帶重建治療新鮮和陳舊性 Neer Ⅱb 型鎖骨遠端骨折的療效比較. 中華創傷骨科雜志, 2022, 24(2): 120-126.
13.	Salazar BP, Chen MJ, Bishop JA, et al. Outcomes after locking plate fixation of distal clavicle fractures with and without coracoclavicular ligament augmentation. Eur J Orthop Surg Traumatol, 2021, 31(3): 473-479.
14.	吳劍宏, 吳曉明, 韓志華, 等. 喙鎖韌帶重建結合鋼板固定治療伴喙鎖韌帶鎖骨止點撕脫的鎖骨遠端骨折. 中華骨科雜志, 2020, 40(1): 17-22.
15.	段學濤. 鎖定鋼板聯合縫合錨在 Neer ⅡB 型鎖骨遠端骨折患者中的應用價值. 河南醫學研究, 2020, 29(29): 5454-5456.
16.	張玉富, 米萌, 張健, 等. 單獨鎖定鋼板和鎖定鋼板聯合縫合錨治療不穩定型鎖骨遠端骨折的病例對照研究. 中國骨傷, 2019, 32(1): 11-16.
17.	Xu H, Chen WJ, Zhi XC, et al. Comparison of the efficacy of a distal clavicular locking plate with and without a suture anchor in the treatment of Neer IIb distal clavicle fractures. BMC Musculoskelet Disord, 2019, 20(1): 503.
18.	王傳宇, 史宗新, 于遠洋, 等. 聯合帶線錨釘功能重建鎖骨遠端 Neer Ⅱb 型骨折中喙鎖韌帶的意義. 中華肩肘外科電子雜志, 2018, 6(2): 120-124.
19.	湯紅偉, 殷勇, 韓擎天, 等. 解剖鎖定鋼板內固定聯合喙鎖韌帶重建治療 Neer Ⅱb 型鎖骨遠端骨折的療效研究. 中國修復重建外科雜志, 2018, 32(9): 1181-1186.
20.	曹冬子, 王存良, 劉宏平, 等. 解剖型鎖定鋼板聯合鈦纜治療 Neer Ⅱ型鎖骨遠端骨折的研究. 西南國防醫藥, 2018, 28(11): 1092-1094.
21.	曾金才, 朱立帆, 吳衛東, 等. 喙鎖固定聯合解剖鎖定板治療不穩定鎖骨遠端骨折的療效. 中華創傷雜志, 2017, 33(3): 263-267.
22.	Fan J, Zhang Y, Huang Q, et al. Comparison of treatment of acute unstable distal clavicle fractures using anatomical locking plates with versus without additional suture anchor fixation. Med Sci Monit, 2017, 23: 5455-5461.
23.	Jeon YM, Ko BS, Park JW. Distal clavicle fracture treated with a titanium elastic nail (TEN). Trauma Case Rep, 2018, 19: 11-14.
24.	Tsuei YC, Au MK, Chu W. Comparison of clinical results of surgical treatment for unstable distal clavicle fractures by transacromial pins with and without tension band wire. J Chin Med Assoc, 2010, 73(12): 638-643.
25.	?ükür E, ?ztürkmen Y, Akman YE, et al. Clinical and radiological results on the fixation of Neer type 2 distal clavicle fractures with a hook plate. Acta Orthop Traumatol Turc, 2016, 50(5): 489-493.
26.	Lee W, Choi CH, Choi YR, et al. Clavicle hook plate fixation for distal-third clavicle fracture (Neer type II): comparison of clinical and radiologic outcomes between Neer types IIA and IIB. J Shoulder Elbow Surg, 2017, 26(7): 1210-1215.
27.	Lee SJ, Eom TW, Hyun YS. Complications and frequency of surgical treatment with AO-type hook plate in shoulder trauma: a retrospective study. J Clin Med, 2022, 11(4): 1026.
28.	Lopiz Y, Checa P, García-Fernández C, et al. Complications with the clavicle hook plate after fixation of Neer type II clavicle fractures. Int Orthop, 2019, 43(7): 1701-1708.
29.	Malik SS, Malik S, Tahir M, et al. Open coraco-clavicular ligament reconstruction (CCLR) in treatment of displaced distal clavicle fractures has low complication rate and excellent union rate: a systematic review. Arch Orthop Trauma Surg, 2023, 143(3): 1459-1477.
30.	Malik SS, Tahir M, Malik S, et al. Arthroscopically assisted coraco-clavicular ligament reconstruction in treatment of acute displaced distal clavicle fractures provides good to excellent shoulder function despite low union rates and high complication rates: a systematic review. Arthroscopy, 2022, 38(2): 567-582.
31.	胡喜春, 黃長明, 范華強, 等. 解剖型鎖定鋼板聯合線纜重建喙鎖韌帶治療鎖骨遠端骨折. 臨床骨科雜志, 2019, 22(4): 417.
32.	Wang HK, Liang LS, He RG, et al. Comparative analysis of locking plates versus hook plates in the treatment of Neer type II distal clavicle fractures. J Int Med Res, 2020, 48(4): 300060520918060.
33.	Beirer M, Siebenlist S, Cr?nlein M, et al. Clinical and radiological outcome following treatment of displaced lateral clavicle fractures using a locking compression plate with lateral extension: a prospective study. BMC Musculoskelet Disord, 2014, 15: 380.
34.	Brouwer KM, Wright TC, Ring DC. Failure of superior locking clavicle plate by axial pull-out of the lateral screws: a report of four cases. J Shoulder Elbow Surg, 2009, 18(1): e22-e25.
35.	Zhang F, Fu Q, Li Y, et al. Locking plate combined with titanium cable for Neer type II distal clavicle fractures. BMC Musculoskelet Disord, 2021, 22(1): 269.
36.	Madsen W, Yaseen Z, LaFrance R, et al. Addition of a suture anchor for coracoclavicular fixation to a superior locking plate improves stability of type IIB distal clavicle fractures. Arthroscopy, 2013, 29(6): 998-1004.
37.	Fahmy FS, ElAttar M, Abulsoud M, et al. Comparative evaluation of arthroscopically assisted coracoclavicular fixation versus hook plate fixation for unstable distal clavicle fractures: a minimum 2-year follow-up study. Orthop J Sports Med, 2022, 10(11): 23259671221137337.
38.	Robinson CM, Bell KR, Murray IR. Open reduction and tunneled suspensory device fixation of displaced lateral-end clavicular fractures: medium-term outcomes and complications after treatment. J Bone Joint Surg Am, 2019, 101(15): 1335-1341.

1. Sandstrom CK, Gross JA, Kennedy SA. Distal clavicle fracture radiography and treatment: a pictorial essay. Emerg Radiol, 2018, 25(3): 311-319.
2. NEER CS 2nd. Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma, 1963, 3: 99-110.
3. Neer CS 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res, 1968, 58: 43-50.
4. Hall JA, Schemitsch CE, Vicente MR, et al. Operative versus nonoperative treatment of acute displaced distal clavicle fractures: a multicenter randomized controlled trial. J Orthop Trauma, 2021, 35(12): 660-666.
5. 韋永安, 周繼輝, 陳文瑤, 等. 鎖骨遠端骨折治療及內置物的選擇. 中國組織工程研究, 2021, 25(30): 4877-4882.
6. Shin SJ, Ko YW, Lee J, et al. Use of plate fixation without coracoclavicular ligament augmentation for unstable distal clavicle fractures. J Shoulder Elbow Surg, 2016, 25(6): 942-948.
7. Kapicioglu M, Erden T, Bilgin E, et al. All arthroscopic coracoclavicular button fixation is efficient for Neer type II distal clavicle fractures. Knee Surg Sports Traumatol Arthrosc, 2021, 29(7): 2064-2069.
8. Robinson PG, Williamson TR, Yapp LZ, et al. Functional outcomes and complications following combined locking plate and tunneled suspensory device fixation of lateral-end clavicle nonunions. J Shoulder Elbow Surg, 2021, 30(11): 2570-2576.
9. Xie Z, Song M, Zhou J, et al. Precontoured locking compression plate with titanium alloy cable system: in treatment of neer type IIb distal clavicle fracture. Orthop Surg, 2021, 13(2): 451-457.
10. Han L, Hu Y, Quan R, et al. Treatment of Neer IIb distal clavicle fractures using anatomical locked plate fixation with coracoclavicular ligament augmentation. J Hand Surg Am, 2017, 42(12): 1036.e1-1036.e6.
11. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9): 603-605.
12. 馬昌科, 沈憶新, 陽利武. 單純解剖鎖定鋼板內固定與聯合喙鎖韌帶重建治療新鮮和陳舊性 Neer Ⅱb 型鎖骨遠端骨折的療效比較. 中華創傷骨科雜志, 2022, 24(2): 120-126.
13. Salazar BP, Chen MJ, Bishop JA, et al. Outcomes after locking plate fixation of distal clavicle fractures with and without coracoclavicular ligament augmentation. Eur J Orthop Surg Traumatol, 2021, 31(3): 473-479.
14. 吳劍宏, 吳曉明, 韓志華, 等. 喙鎖韌帶重建結合鋼板固定治療伴喙鎖韌帶鎖骨止點撕脫的鎖骨遠端骨折. 中華骨科雜志, 2020, 40(1): 17-22.
15. 段學濤. 鎖定鋼板聯合縫合錨在 Neer ⅡB 型鎖骨遠端骨折患者中的應用價值. 河南醫學研究, 2020, 29(29): 5454-5456.
16. 張玉富, 米萌, 張健, 等. 單獨鎖定鋼板和鎖定鋼板聯合縫合錨治療不穩定型鎖骨遠端骨折的病例對照研究. 中國骨傷, 2019, 32(1): 11-16.
17. Xu H, Chen WJ, Zhi XC, et al. Comparison of the efficacy of a distal clavicular locking plate with and without a suture anchor in the treatment of Neer IIb distal clavicle fractures. BMC Musculoskelet Disord, 2019, 20(1): 503.
18. 王傳宇, 史宗新, 于遠洋, 等. 聯合帶線錨釘功能重建鎖骨遠端 Neer Ⅱb 型骨折中喙鎖韌帶的意義. 中華肩肘外科電子雜志, 2018, 6(2): 120-124.
19. 湯紅偉, 殷勇, 韓擎天, 等. 解剖鎖定鋼板內固定聯合喙鎖韌帶重建治療 Neer Ⅱb 型鎖骨遠端骨折的療效研究. 中國修復重建外科雜志, 2018, 32(9): 1181-1186.
20. 曹冬子, 王存良, 劉宏平, 等. 解剖型鎖定鋼板聯合鈦纜治療 Neer Ⅱ型鎖骨遠端骨折的研究. 西南國防醫藥, 2018, 28(11): 1092-1094.
21. 曾金才, 朱立帆, 吳衛東, 等. 喙鎖固定聯合解剖鎖定板治療不穩定鎖骨遠端骨折的療效. 中華創傷雜志, 2017, 33(3): 263-267.
22. Fan J, Zhang Y, Huang Q, et al. Comparison of treatment of acute unstable distal clavicle fractures using anatomical locking plates with versus without additional suture anchor fixation. Med Sci Monit, 2017, 23: 5455-5461.
23. Jeon YM, Ko BS, Park JW. Distal clavicle fracture treated with a titanium elastic nail (TEN). Trauma Case Rep, 2018, 19: 11-14.
24. Tsuei YC, Au MK, Chu W. Comparison of clinical results of surgical treatment for unstable distal clavicle fractures by transacromial pins with and without tension band wire. J Chin Med Assoc, 2010, 73(12): 638-643.
25. ?ükür E, ?ztürkmen Y, Akman YE, et al. Clinical and radiological results on the fixation of Neer type 2 distal clavicle fractures with a hook plate. Acta Orthop Traumatol Turc, 2016, 50(5): 489-493.
26. Lee W, Choi CH, Choi YR, et al. Clavicle hook plate fixation for distal-third clavicle fracture (Neer type II): comparison of clinical and radiologic outcomes between Neer types IIA and IIB. J Shoulder Elbow Surg, 2017, 26(7): 1210-1215.
27. Lee SJ, Eom TW, Hyun YS. Complications and frequency of surgical treatment with AO-type hook plate in shoulder trauma: a retrospective study. J Clin Med, 2022, 11(4): 1026.
28. Lopiz Y, Checa P, García-Fernández C, et al. Complications with the clavicle hook plate after fixation of Neer type II clavicle fractures. Int Orthop, 2019, 43(7): 1701-1708.
29. Malik SS, Malik S, Tahir M, et al. Open coraco-clavicular ligament reconstruction (CCLR) in treatment of displaced distal clavicle fractures has low complication rate and excellent union rate: a systematic review. Arch Orthop Trauma Surg, 2023, 143(3): 1459-1477.
30. Malik SS, Tahir M, Malik S, et al. Arthroscopically assisted coraco-clavicular ligament reconstruction in treatment of acute displaced distal clavicle fractures provides good to excellent shoulder function despite low union rates and high complication rates: a systematic review. Arthroscopy, 2022, 38(2): 567-582.
31. 胡喜春, 黃長明, 范華強, 等. 解剖型鎖定鋼板聯合線纜重建喙鎖韌帶治療鎖骨遠端骨折. 臨床骨科雜志, 2019, 22(4): 417.
32. Wang HK, Liang LS, He RG, et al. Comparative analysis of locking plates versus hook plates in the treatment of Neer type II distal clavicle fractures. J Int Med Res, 2020, 48(4): 300060520918060.
33. Beirer M, Siebenlist S, Cr?nlein M, et al. Clinical and radiological outcome following treatment of displaced lateral clavicle fractures using a locking compression plate with lateral extension: a prospective study. BMC Musculoskelet Disord, 2014, 15: 380.
34. Brouwer KM, Wright TC, Ring DC. Failure of superior locking clavicle plate by axial pull-out of the lateral screws: a report of four cases. J Shoulder Elbow Surg, 2009, 18(1): e22-e25.
35. Zhang F, Fu Q, Li Y, et al. Locking plate combined with titanium cable for Neer type II distal clavicle fractures. BMC Musculoskelet Disord, 2021, 22(1): 269.
36. Madsen W, Yaseen Z, LaFrance R, et al. Addition of a suture anchor for coracoclavicular fixation to a superior locking plate improves stability of type IIB distal clavicle fractures. Arthroscopy, 2013, 29(6): 998-1004.
37. Fahmy FS, ElAttar M, Abulsoud M, et al. Comparative evaluation of arthroscopically assisted coracoclavicular fixation versus hook plate fixation for unstable distal clavicle fractures: a minimum 2-year follow-up study. Orthop J Sports Med, 2022, 10(11): 23259671221137337.
38. Robinson CM, Bell KR, Murray IR. Open reduction and tunneled suspensory device fixation of displaced lateral-end clavicular fractures: medium-term outcomes and complications after treatment. J Bone Joint Surg Am, 2019, 101(15): 1335-1341.

West China Medical Journal

A meta-analysis of the necessity of coracoclavicular ligament reconstruction in the treatment of unstable distal clavicular fractures with locking plate

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