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Operative Therapie der Klavikulapseudarthrose

Beckenkammaugmentation und anatomische winkelstabile Platte

Operative management of clavicular non-union

Iliac crest bone graft and anatomic locking compression plate

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Zusammenfassung

Operationsziel

Ziel der Therapie bei Klavikulapseudarthrose ist die anatomische Rekonstruktion der Klavikula mittels Beckenkammaugmentation und winkelstabiler Plattenosteosynthese.

Indikationen

Pseudarthrosen oder Knochendefekte der Klavikula mit einer Defektlänge > 1,5 cm.

Kontraindikationen

Jeglicher Infektverdacht. Erhöhtes Risiko des Nichteinheilens des Transplantats oder einer Rezidivpseudarthrose aufgrund von Nebenerkrankungen/Medikamenteneinnahme, Nikotinabusus (>10 Stck./Tag). Mangelnde Compliance des Patienten hinsichtlich spezifischer Nachbehandlung. Reduzierter Allgemeinzustand mit eingeschränkter Operationsfähigkeit.

Operationstechnik

Beach-Chair-Lagerung mit beweglicher Lagerung des betroffenen Arms. Hautinzision längs am Unterrand der Klavikula, Längsspalten der klavipektoralen Faszie, Inzision des Periostschlauchs. Komplexe (mehrdimensionale) Klavikulaosteotomie medial und lateral der Pseudarthrose bis hin zum vitalen Knochen. Bemessen der Resektionsränder und Berechnung der Größe des erforderlichen Beckenkammtransplantats in Abhängigkeit von der präoperativen CT-Planung mit der gesunden Gegenseite als Zielgröße. Heben eines trikortikalen Beckenkammspans zur Defektdeckung. Konfektionieren des Beckenkammspans an den Defekt. Anlage einer anatomischen winkelstabilen Platte (LCP Superiore Anteriore Klavikulaplatte, Depuy Synthes, Umkirch, Deutschland) mit oder ohne seitliche Verlängerung und, fluoroskopisch gestützt, schrittweises Besetzen derselben mit Schrauben. Bei Bedarf zusätzliche Sicherung des Transplantats mittels Fadencerclage (FiberWire, Arthrex, Karlsfeld, Deutschland) oder Schraube. Radiologische Abschlusskontrolle. Blutstillung am Beckenkamm (Einlage mit Lyostypt-Kollagenvlies, B. Braun Melsungen AG, getränkt mit Naropin) und Klavikula. Bei Bedarf Einlage einer Drainage, schichtgerechte Wundnaht. Anlage einer Schultergelenksbandage.

Nachbehandlung

Tragen der Schultergelenksbandage für 6 Wochen mit schrittweiser Freigabe der Beweglichkeit. Freie Beweglichkeit ab der 7., volle Belastbarkeit ab der 12. Woche. Radiologische Kontrollen 3, 6, 12 und 24 Wochen postoperativ. Metallentfernung frühestens nach 2 Jahren.

Ergebnisse

In unserem eigenen Patientengut von bislang 10 konsekutiven Patienten mit einem Follow-up > 1 Jahr konnte mit der Technik eine radiologisch gesicherte anatomische Ausheilung bei sehr guter Patientenzufriedenheit erzielt werden.

Abstract

Objective

The objective in treating clavicular non-union is an anatomic reconstruction of the clavicle with an iliac crest bone graft and anatomic locking compression plates.

Indications

Non-union or bony defects of the clavicle larger than 1.5 cm.

Contraindications

Any suspicion of infection, elevated risk of transplant necrosis or recurrent non-union due to concomitant disease, medication, cigarette smoking (>10 cig./d), poor therapeutic compliance regarding specific postoperative management and poor physical status.

Surgical technique

Patient in beach chair position with a flexible affected arm. An longitudinal skin incision is made below the clavicle with subsequent incision through the clavipectoral fascia and the periosteum, complex multidimensional osteotomy of the clavicle with medial and lateral axial correction of the pseudarthrosis up to vital bone, harvesting of a tricortical iliac crest bone graft with the size measured in preoperative computed tomography (CT) according to the length of the healthy contralateral clavicle. Final shaping of the iliac crest bone graft regarding the future clavicular position, positioning of the anatomic plate (LCP superior anterior clavicle plate with or without lateral extension, Depuy Synthes, Umkirch, Germany) and drilling and screw insertion under radiological guidance. If necessary additional attachment of the iliac crest bone graft with suture cerclage (FiberWire, Arthrex, Karlsfeld, Germany) or screw should be carried out. A final radiological examination and hemostasis of the iliac crest with a Lyostypt collagen hemostatic fleece and the clavicle. Drains might be needed and wound closure layer by layer with sutures.

Postoperative management

Arm sling protection for 6 weeks with physiotherapeutic exercises and increased range of motion every 2 weeks and unrestricted range of motion from week 7 onwards. Full weight bearing is not allowed before week 12 and X-ray examinations to confirm bone healing should be done 3, 6, 12 and 24 weeks postoperatively. Implant removal at an earliest time point of 2 years can be performed when full osseous integration of the graft is radiologically confirmed.

Results

At our department 10 consecutive patients suffering from clavicular non-union have been treated with this technique with a minimum follow-up of 1 year. All patients showed anatomic restoration of the radiologically confirmed healed clavicle with very good patient satisfaction.

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Literatur

  1. Alshameeri ZA, Katam K, Alsamaq M et al (2012) The outcome of surgical fixation of mid shaft clavicle fractures; looking at patient satisfaction and comparing surgical approaches. Int J Shoulder Surg 6:76–81

    Article  PubMed  Google Scholar 

  2. Boehme D, Curtis RJ Jr, Dehaan JT et al (1991) Non-union of fractures of the mid-shaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting. J Bone Joint Surg Am 73:1219–1226

    PubMed  CAS  Google Scholar 

  3. Bradbury N, Hutchinson J, Hahn D et al (1996) Klavikular nonunion. 31/32 healed after plate fixation and bone grafting. Acta Orthop Scand 67:367–370

    Article  PubMed  CAS  Google Scholar 

  4. Canadian Orthopaedic Trauma Society (2007) Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 89:1–10

    Google Scholar 

  5. D’heurle A, Le T, Grawe B et al (2013) Perioperative risks associated with the operative treatment of clavicle fractures. Injury (Epub ahead of print)

  6. Dahabreh Z, Dimitriou R, Giannoudis PV (2007) Health economics: a cost analysis of treatment of persistent fracture non-unions using bone morphogenetic protein-7. Injury 38:371–377

    Article  PubMed  Google Scholar 

  7. Dimitriou R, Dahabreh Z, Katsoulis E et al (2005) Application of recombinant BMP-7 on persistent upper and lower limb non-unions. Injury 36(Suppl 4):S51–S59

    Article  PubMed  Google Scholar 

  8. Ebraheim NA, Mekhail AO, Darwich M (1997) Open reduction and internal fixation with bone grafting of Klavikular nonunion. J Trauma 42:701–704

    Article  PubMed  CAS  Google Scholar 

  9. Eden L, Doht S, Frey SP et al (2012) Biomechanical comparison of the locking compression superior anterior clavicle plate with seven and ten hole reconstruction plates in midshaft clavicle fracture stabilisation. Int Orthop 36:2537–2543

    Article  PubMed  Google Scholar 

  10. Glotzbecker MP, Shin EK, Chen NC et al (2009) Salvage reconstruction of congenital pseudarthrosis of the clavicle with vascularized fibular graft after failed operative treatment: a case report. J Pediatr Orthop 29:411–415

    Article  PubMed  Google Scholar 

  11. Hackenbruch W, Gumppenberg S von (1982) Operative therapy of clavicular pseudarthrosis. Unfallheilkunde 85:478–481

    PubMed  CAS  Google Scholar 

  12. Heary RF, Schlenk RP, Sacchieri TA et al (2002) Persistent iliac crest donor site pain: independent outcome assessment. Neurosurgery 50:510–516 (discussion 516–517)

    PubMed  Google Scholar 

  13. Jubel A, Andermahr J, Weisshaar G et al (2005) Intramedullary nailing (ESIN) in clavicular pseudoarthroses. Results of a prospective clinical trial. Unfallchirurg 108:544–550

    Article  PubMed  CAS  Google Scholar 

  14. Jupiter JB, Leffert RD (1987) Non-union of the clavicle. Associated complications and surgical management. J Bone Joint Surg Am 69:753–760

    PubMed  CAS  Google Scholar 

  15. Kabak S, Halici M, Tuncel M et al (2004) Treatment of mid clavicular nonunion: comparison of dynamic compression plating and low-contact dynamic compression plating techniques. J Shoulder Elbow Surg 13:396–403

    Article  PubMed  Google Scholar 

  16. Khu KJ, Midha R (2010) Clavicle pseudarthrosis: a rare cause of thoracic outlet syndrome. Can J Neurol Sci 37:863–865

    PubMed  Google Scholar 

  17. Kim DH, Rhim R, Li L et al (2009) Prospective study of iliac crest bone graft harvest site pain and morbidity. Spine J 9:886–892

    Article  PubMed  Google Scholar 

  18. Lee SK, Lee JW, Song DG et al (2013) Precontoured locking plate fixation for displaced lateral clavicle fractures. Orthopedics 36:801–807

    Article  PubMed  Google Scholar 

  19. Martetschlager F, Gaskill TR, Millett PJ (2013) Management of clavicle nonunion and malunion. J Shoulder Elbow Surg 22:862–868

    Article  PubMed  Google Scholar 

  20. Marti RK, Nolte PA, Kerkhoffs GM et al (2003) Operative treatment of mid-shaft clavicular non-union. Int Orthop 27:131–135

    PubMed  CAS  Google Scholar 

  21. Moseley HF (1968) The clavicle: its anatomy and function. Clin Orthop Relat Res 58:17–27

    Article  PubMed  CAS  Google Scholar 

  22. Murray IR, Foster CJ, Eros A et al (2013) Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures of the clavicle. J Bone Joint Surg Am 95:1153–1158

    Article  PubMed  CAS  Google Scholar 

  23. Pedersen M, Poulsen KA, Thomsen F et al (1994) Operative treatment of clavicular nonunion. Acta Orthop Belg 60:303–306

    PubMed  CAS  Google Scholar 

  24. Petrovic I, Davila S, Premuzic I et al (2004) Long-term outcomes of clavicular pseudoarthrosis therapy. J Surg Res 121:222–227

    Article  PubMed  CAS  Google Scholar 

  25. Rhinelander FW (1974) Tibial blood supply in relation to fracture healing. Clin Orthop Relat Res 34–81

  26. Rolf O, Kallmayer M, Von Weyhern AH et al (2008) The anatomical precontoured Meves compression plate: surgical treatment of clavicular nonunion. Orthopade 37:457–461

    Article  PubMed  CAS  Google Scholar 

  27. Tiren D, Vroemen JP (2013) Superior clavicle plate with lateral extension for displaced lateral clavicle fractures: a prospective study. J Orthop Traumatol 14:115–120

    Article  PubMed  Google Scholar 

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Einhaltung ethischer Richtlinien

Interessenkonflikt. C. Kirchhoff, I.J. Banke, M. Beirer und P. Biberthaler geben an, dass kein Interessenkonflikt besteht. A.B. Imhoff übt eine Beraterfunktion bei der Fa. Arthrex aus. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren. Alle Patienten, die über Bildmaterial oder anderweitige Angaben innerhalb des Manuskripts zu identifizieren sind, haben hierzu ihre schriftliche Einwilligung gegeben. Im Falle von nicht mündigen Patienten liegt die Einwilligung eines Erziehungsberechtigen oder des gesetzlich bestellten Betreuers vor.

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Authors and Affiliations

  1. Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland

    C. Kirchhoff, I.J. Banke, M. Beirer & P. Biberthaler

  2. Abteilung für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland

    A.B. Imhoff

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  1. C. Kirchhoff
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  2. I.J. Banke
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Correspondence to C. Kirchhoff.

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C. Kirchhoff und I.J. Banke haben zu gleichen Teilen zu dieser Arbeit beigetragen.

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Kirchhoff, C., Banke, I., Beirer, M. et al. Operative Therapie der Klavikulapseudarthrose. Oper Orthop Traumatol 25, 483–498 (2013). https://doi.org/10.1007/s00064-013-0257-0

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