title: Additional bone graft accelerates healing of clavicle non-unions and improves long-term results after 8.9 years: a retrospective study.
abstract: BACKGROUND
  Clavicle non-unions can occur after both conservative and operative treatment failure. Here, we investigated the outcome of patients with delayed fracture healing or non-unions of the clavicle. Patients underwent revision surgery by plate osteosynthesis of the clavicle with or without bone grafting. Our aim was to determine rates of bone healing and the functional long-term outcome.
  
  
  METHODS
  The study population of 58 consecutive patients was divided into group 1 (n = 25; no bone graft) and group 2 (n = 33; iliac crest bone graft). Bone consolidation was determined by the Lane-Sandhu score preoperatively and after 2.2 ± 1.8 years, respectively. The functional long-term outcome was determined after 8.9 ± 2.7 years in all available patients (n = 30) by the Constant score, DASH (Disabilities of the Arm, Shoulder and Hand) score and SF-36, and clavicle length was measured by ultrasound as compared to the healthy side.
  
  
  RESULTS
  Clavicle consolidation was achieved in 54 out of 58 patients (93.1%) after revision surgeries. The radiographic score and bone consolidation rates were significantly higher in group 2 (93.3%) as compared with 72% in group 1 (p = 0.02), resulting in a significantly shorter time to bone consolidation in group 2. Similarly, the relative risk for additional surgery after the first revision surgery was 4.7-fold higher in group 1 (p = 0.02). The long-term results showed overall very good results in DASH score (14.9 ± 16.5) and good results in Constant scores (77.9 ± 19.9). The group analyses found significantly better Constant scores and better visual analogue pain scale (VAS) numbers in group 2. Clavicle shortening appeared to affect the clinical results, and a mild correlation between shortening and Constant scores (R = -0.31) was found.
  
  
  CONCLUSIONS
  This study shows high rates of bone healing and good functional outcomes after surgical revision of clavicle non-unions and further demonstrates that additional bone graft could significantly accelerate bone healing. This indicates that revision surgery of clavicle non-unions might preferably be done with additional bone graft, even if the surgeon considers that bone healing might be achieved without bone grafting.
authors.affiliation: Department of Orthopaedic and Trauma Surgery, BG Unfallklinik Ludwigshafen, Ludwig Guttmann Strasse 13, 67071, Ludwigshafen am Rhein, Germany. marcschnetzke@gmx.de.
authors.forename: Marc
authors.initials: M
authors.lastname: Schnetzke
authors.affiliation: Department of Surgery, Kreiskrankenhaus Grünstadt, Westring 55, 67269, Grünstadt, Germany. chris_mor@t-online.de.
authors.forename: Christian
authors.initials: C
authors.lastname: Morbitzer
authors.affiliation: Department of Orthopaedic and Trauma Surgery, BG Unfallklinik Ludwigshafen, Ludwig Guttmann Strasse 13, 67071, Ludwigshafen am Rhein, Germany. Robespierre1794@gmx.de.
authors.forename: Sara
authors.initials: S
authors.lastname: Aytac
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Klinikum Mittelbaden Baden-Baden Balg, Klinikum Mittelbaden GmbH, Balger Str. 50, 76532, Baden-Baden, Germany. erhardts@gmx.de.
authors.forename: Matthias
authors.initials: M
authors.lastname: Erhardt
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Klinikum Mittelbaden Baden-Baden Balg, Klinikum Mittelbaden GmbH, Balger Str. 50, 76532, Baden-Baden, Germany. christian.b.frank@t-online.de.
authors.forename: Christian
authors.initials: C
authors.lastname: Frank
authors.affiliation: Department of Orthopaedic and Trauma Surgery, BG Unfallklinik Ludwigshafen, Ludwig Guttmann Strasse 13, 67071, Ludwigshafen am Rhein, Germany. matthias.muenzberg@bgu-ludwigshafen.de.
authors.forename: Matthias
authors.initials: M
authors.lastname: Muenzberg
authors.affiliation: Department of Orthopaedic and Trauma Surgery, BG Unfallklinik Ludwigshafen, Ludwig Guttmann Strasse 13, 67071, Ludwigshafen am Rhein, Germany. stefan.studier-fischer@bgu-ludwigshafen.de.
authors.forename: Stefan
authors.initials: S
authors.lastname: Studier-Fischer
authors.affiliation: Department of Orthopaedic Surgery, University of Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany. lars_helbig@t-online.de.
authors.forename: Lars
authors.initials: L
authors.lastname: Helbig
authors.affiliation: Department of Orthopaedic and Trauma Surgery, BG Unfallklinik Ludwigshafen, Ludwig Guttmann Strasse 13, 67071, Ludwigshafen am Rhein, Germany. arnold.suda@bgu-ludwigshafen.de.
authors.forename: Arnold J
authors.initials: AJ
authors.lastname: Suda
authors.affiliation: Department of Orthopaedic and Trauma Surgery, BG Unfallklinik Ludwigshafen, Ludwig Guttmann Strasse 13, 67071, Ludwigshafen am Rhein, Germany. paul.gruetzner@bgu-ludwigshafen.de.
authors.forename: Paul-Alfred
authors.initials: PA
authors.lastname: Gruetzner
authors.affiliation: Department of Orthopaedic and Trauma Surgery, BG Unfallklinik Ludwigshafen, Ludwig Guttmann Strasse 13, 67071, Ludwigshafen am Rhein, Germany. guehring@uni-heidelberg.de.
authors.forename: Thorsten
authors.initials: T
authors.lastname: Guehring
mesh_terms: D000328:Adult; D000368:Aged; D001860:Bone Plates; D016025:Bone Transplantation; D002968:Clavicle / Q000000981:diagnostic imaging / Q000293:injuries*; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D005599:Fractures, Ununited / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012086:Reoperation; D012189:Retrospective Studies; D017211:Treatment Failure; D055815:Young Adult