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.	韦永安, 周继辉, 陈文瑶, 等. 锁骨远端骨折治疗及内置物的选择. 中国组织工程研究, 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.	马昌科, 沈忆新, 阳利武. 单纯解剖锁定钢板内固定与联合喙锁韧带重建治疗新鲜和陈旧性 Neer Ⅱb 型锁骨远端骨折的疗效比较. 中华创伤骨科杂志, 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.	吴剑宏, 吴晓明, 韩志华, 等. 喙锁韧带重建结合钢板固定治疗伴喙锁韧带锁骨止点撕脱的锁骨远端骨折. 中华骨科杂志, 2020, 40(1): 17-22.
15.	段学涛. 锁定钢板联合缝合锚在 Neer ⅡB 型锁骨远端骨折患者中的应用价值. 河南医学研究, 2020, 29(29): 5454-5456.
16.	张玉富, 米萌, 张健, 等. 单独锁定钢板和锁定钢板联合缝合锚治疗不稳定型锁骨远端骨折的病例对照研究. 中国骨伤, 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.	王传宇, 史宗新, 于远洋, 等. 联合带线锚钉功能重建锁骨远端 Neer Ⅱb 型骨折中喙锁韧带的意义. 中华肩肘外科电子杂志, 2018, 6(2): 120-124.
19.	汤红伟, 殷勇, 韩擎天, 等. 解剖锁定钢板内固定联合喙锁韧带重建治疗 Neer Ⅱb 型锁骨远端骨折的疗效研究. 中国修复重建外科杂志, 2018, 32(9): 1181-1186.
20.	曹冬子, 王存良, 刘宏平, 等. 解剖型锁定钢板联合钛缆治疗 Neer Ⅱ型锁骨远端骨折的研究. 西南国防医药, 2018, 28(11): 1092-1094.
21.	曾金才, 朱立帆, 吴卫东, 等. 喙锁固定联合解剖锁定板治疗不稳定锁骨远端骨折的疗效. 中华创伤杂志, 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.	Şükür E, Öztürkmen 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, 黄长明, 范华强, 等. 解剖型锁定钢板联合线缆重建喙锁韧带治疗锁骨远端骨折. 临床骨科杂志, 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, Crönlein 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. 韦永安, 周继辉, 陈文瑶, 等. 锁骨远端骨折治疗及内置物的选择. 中国组织工程研究, 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. 马昌科, 沈忆新, 阳利武. 单纯解剖锁定钢板内固定与联合喙锁韧带重建治疗新鲜和陈旧性 Neer Ⅱb 型锁骨远端骨折的疗效比较. 中华创伤骨科杂志, 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. 吴剑宏, 吴晓明, 韩志华, 等. 喙锁韧带重建结合钢板固定治疗伴喙锁韧带锁骨止点撕脱的锁骨远端骨折. 中华骨科杂志, 2020, 40(1): 17-22.
15. 段学涛. 锁定钢板联合缝合锚在 Neer ⅡB 型锁骨远端骨折患者中的应用价值. 河南医学研究, 2020, 29(29): 5454-5456.
16. 张玉富, 米萌, 张健, 等. 单独锁定钢板和锁定钢板联合缝合锚治疗不稳定型锁骨远端骨折的病例对照研究. 中国骨伤, 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. 王传宇, 史宗新, 于远洋, 等. 联合带线锚钉功能重建锁骨远端 Neer Ⅱb 型骨折中喙锁韧带的意义. 中华肩肘外科电子杂志, 2018, 6(2): 120-124.
19. 汤红伟, 殷勇, 韩擎天, 等. 解剖锁定钢板内固定联合喙锁韧带重建治疗 Neer Ⅱb 型锁骨远端骨折的疗效研究. 中国修复重建外科杂志, 2018, 32(9): 1181-1186.
20. 曹冬子, 王存良, 刘宏平, 等. 解剖型锁定钢板联合钛缆治疗 Neer Ⅱ型锁骨远端骨折的研究. 西南国防医药, 2018, 28(11): 1092-1094.
21. 曾金才, 朱立帆, 吴卫东, 等. 喙锁固定联合解剖锁定板治疗不稳定锁骨远端骨折的疗效. 中华创伤杂志, 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. Şükür E, Öztürkmen 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, 黄长明, 范华强, 等. 解剖型锁定钢板联合线缆重建喙锁韧带治疗锁骨远端骨折. 临床骨科杂志, 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, Crönlein 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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