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Yoyos Dias Ismiarto

Controversies in Orthopaedic : Superior VERSUS Anteroinferior Plating of Clavicle Fractures. Yoyos Dias Ismiarto. Orthopaedic and Traumatology Department Faculty of Medicine Universitas Padjadjaran Hasan Sadikin General Hospital Bandung. Background.

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Yoyos Dias Ismiarto

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  1. Controversies in Orthopaedic : Superior VERSUS Anteroinferior Plating of Clavicle Fractures Yoyos Dias Ismiarto Orthopaedic and Traumatology Department Faculty of Medicine Universitas Padjadjaran Hasan Sadikin General Hospital Bandung

  2. Background • Clavicle fractures  common injury of shoulder girdle  vast majority are middle 3rd of clavicle

  3. Background A prospective randomized trial showed  functional outcomes &  non-union and malunion rates for surgical fixation

  4. Superior Plating • Most common, useful in inferior cortical comminution • Greater load to failure & bending failure stiffness • Greater risk to injury underlying neurovascular structure • Plate prominence  hardware removal surgery

  5. Anterior Plating • Allows longer screw placement as plate sits perpendicular to “widest” portion of oval, obliquely oriented clavicle • Screws are directed away from vital neurovascular structures including subclavian vein & artery • Less plate prominence  less pain/irritation   reoperation rates for implant removal

  6. Anterior plates  more resistant to compression / axial forces • Superior plates  more resistant to 3-point cantilever bending when no comminution exists

  7. Closest structure to clavicle  subclavian vein  a directly posterior structure (within 4mm) at medial 1/3 of clavicle then it passes posterior  inferior along lateral 3rd Sinh et al. JBJS (Br) 2011; Quin et al. J Trauma 2010; Galley et al. JSES 2009

  8. Average length of adult male/female clavicle  152/137mm • 8 hole anterior plate  102-110mm • Anterior plate will take up about 70% length of clavicle w/ medial most screws in danger Sinh et al. JBJS (Br) 2011; Quin et al. J Trauma 2010; Galley et al. JSES 2009

  9. Safest Screw Placement Sinh et al. JBJS (Br) 2011; Quin et al. J Trauma 2010; Galley et al. JSES 2009

  10. Orthopaedics 2013;36(7):e898-904

  11. Orthopaedics 2013;36(7):e898-904

  12. Most profound symptom Orthopaedics 2013;36(7):e898-904

  13. Not significant statistically Orthopaedics 2013;36(7):e898-904

  14. Both superior and anteroinferior clavicle plating are safe methods of treatment for displaced clavicle fractures with high union rates & few complications

  15. 24 preosteotomized synthetic left clavicles Standard 3.5-mm pelvic recons plate 3.5-mm locking pelvic recons plate Superior position Anteroinferior position 3 nondestructive cyclic mechanical tests  axial, torsion, four-point bend Journal of Orthopaedic Trauma 2010;24(7):420-5

  16. No significant difference in axial (P = 0.61) or torsional stiffness (internal rotation, P = 0.46 or external rotation, P = 0.49) • No significant difference in bending rigidity (four-point bending) with type of plate (P = 0.41) • But when plate was placed anteroinferiorly, bending rigidity was significantly  (P < 0.001) than in superior position

  17. Placing plate anteroinferiorly  more stable construct in terms of bending rigidity • Other advantages of anteroinferior plating avoidance of neurovascular compromise, use of longer screws,  hardware prominence

  18. Comparison of Superior and Anteroinferior Plate Placement in the Treatment of Clavicle FracturesRobert S. Rice, Peter A. Cole, Adam BloemkeOTA 2007 No statistically significant differences were detected with regard to union or infection rates between anteroinferior and superior plating

  19. Biomechanical evaluation of clavicle fracture plating techniques: does a locking plate provide improved stability?Celeste P, Robertson C, Mahar A, Oka R, Meunier M, Schwartz AJ Orthop Trauma 2008;22(4):241-7 Biomechanically, repairing a midshaft clavicle fracture with a superior plate was more favorable compared to anterior-inferior plating in terms of both load to failure and bending failure stiffness

  20. Superior versus anteroinferior plating of the clavicle: a finite element studyFavre P, Kloen P, Helfet DL, Werner CMJ Orthop Trauma 2011;25(11):661-5 • Anterorinferior plating induces deformation modes similar to intact clavicle  less likely to fail during normal physiological loading (cantilever bending) • Superior plating may be recommended for patient with high risk of shoulder impacts (axial compression)

  21. Anterior Versus Superior Plating Of Fresh Displaced  MidshaftClavicular Fractures Venkatachalam, S, Sivaji CK, Shipton A, Packer GJJ Orthopaedics 2007;4(4):e1

  22. The majority of our specimens showed no significant difference between superior and anterior plating in regard to potential risk for injury to the underlying neurovasculature J Orthop Trauma 2013;27(11):627-32

  23. Conclusion • Patient treatment should be individualized • Both superior and anteroinferior clavicle plating are safe methods of treatment for displaced clavicle fractures with high union rates & few complications • Superior plating leads to an increased rate of patient-reported implant prominence and may prompt more requests for implant removal

  24. Thank You…

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