title: Can complications of titanium elastic nailing with end cap for clavicular fractures be reduced?
abstract: BACKGROUND
  We found treatment of clavicular midshaft fractures using titanium elastic nails (TENs) in combination with postoperative free ROM was associated with a complication rate of 78%. The use of end caps reduced the rate to 60%, which we still considered unacceptably high. Thus, we explored an alternative approach.
  
  
  OBJECTIVE
  We investigated whether (1) the complication rate could be reduced by cautious lateral advancement of the TENs, intraoperative oblique radiographs to rule out lateral perforation, and limited ROM postoperatively; (2) fluoroscopy time could be reduced; and (3) shoulder function would be reasonable.
  
  
  METHODS
  From March 2006 to December 2009, we treated 44 patients with midshaft clavicular fractures with TENs and end caps. In the first group (n = 15), the TEN was advanced laterally using an oscillating drill. The patients were permitted free ROM. In the second group (n = 29), the TEN was advanced by hand, conversion to open reduction followed two failed closed attempts and lateral perforation was checked with an intraoperative oblique radiograph. Furthermore, anteversion and abduction of the shoulder were limited to 90° for the first 6 weeks. Minimum followup was 12 months (mean, 16.7 months; range, 12-28 months).
  
  
  RESULTS
  The total complication rate was reduced from nine of 15 in the first group to five of 29 in the second group. Medial perforations ceased with the use of the end cap. Fluoroscopy time was reduced from a mean of 10 to 4 minutes by converting to open reduction after two failed closed attempts. All but three patients exhibited full shoulder ROM at three months and these three had a slight deficit of 10° to 20° in anteversion and/or abduction. At last followup, the mean American Shoulder and Elbow Surgeons score was 92 (range, 88-100) and the Disability of the Arm, Shoulder, and Hand score 1.4 (range, 0-12.5).
  
  
  CONCLUSIONS
  Cautious insertion of the TENs, intraoperative oblique radiographs, and limiting the ROM for 6 weeks postoperatively reduced the complication rate. Using TENs with end caps for midshaft clavicular fractures is minimally invasive while associated with comparable complication rates and function to plate osteosynthesis.
  
  
  METHODS
  Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland. mail@arnofrigg.com
authors.forename: Arno
authors.initials: A
authors.lastname: Frigg
authors.forename: Paavo
authors.initials: P
authors.lastname: Rillmann
authors.forename: Christian
authors.initials: C
authors.lastname: Ryf
authors.forename: Richard
authors.initials: R
authors.lastname: Glaab
authors.forename: Lisa
authors.initials: L
authors.lastname: Reissner
mesh_terms: D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D002968:Clavicle / Q000293:injuries*; D004867:Equipment Design; D005260:Female; D005471:Fluoroscopy; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects* / Q000379:methods; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control; D016059:Range of Motion, Articular; D012785:Shoulder Joint / Q000503:physiopathology; D014025:Titanium; D055815:Young Adult
chemical_list: D014025:Titanium