title: Management of acute unstable distal clavicle fracture with a modified coracoclavicular stabilization technique using a bidirectional coracoclavicular loop system.
abstract: BACKGROUND
  Fracture of the distal clavicle is not uncommon. Despite the vast literature available for the management of this fracture, there is no consensus regarding the gold standard treatment for this fracture.
  
  
  OBJECTIVE
  To assess the clinical and radiographic outcomes and complications of acute unstable distal clavicle fracture when treated by a modified coracoclavicular stabilization technique using a bidirectional coracoclavicular loop system.
  
  
  METHODS
  Thirty-nine patients (32 males, 7 females) with acute unstable distal clavicle fractures treated by modified coracoclavicular stabilization using the surgical technique of bidirectional coracoclavicular (CC) loops seated behind the coracoacromial (CA) ligament were retrospectively reviewed. Mean follow-up time was 35.7 months (range 24-47 months). The outcomes measured included union rate, union time, CC distances when compared to the patients' uninjured shoulders, and the Constant and ASES shoulder scores, which were evaluated 6 months after surgery.
  
  
  RESULTS
  All fractures displayed clinical union within 13 weeks postoperatively. The mean union time was 9.2 weeks (range 7-13 weeks). At the time of union, the CC distances on the affected shoulders were on average 0.9 mm (range 0-1.6 mm) longer than the unaffected shoulders. At 6 months after surgery, the Constant and ASES scores were on average 93.4 (72-100) and 91.5 (75-100), respectively. No complications related to the fixation loops, musculocutaneous nerve injuries, or fractures of coracoid or clavicle were recorded. One case of surgical wound dehiscence was observed due to superficial infection. Enlargement of the clavicle drill hole without migration of the buttons was observed in 9 out of 16 cases at a follow-up time of at least 30 months after the original operation.
  
  
  CONCLUSIONS
  Modified CC stabilization using bidirectional CC loops seated behind the CA ligament is a simple surgical technique that naturally restores stability to the distal clavicle fracture. It also produces predictable outcomes, a high union rate, good to excellent shoulder function, and a low complication rate. The buttons and suture loops were routinely removed in a second operation in order to prevent late stress fracture of the clavicle.
authors.affiliation: Department of Orthopedics, Lerdsin General Hospital, Bangkok, 10500, Thailand. wichanmd@yahoo.com.
authors.forename: Wichan
authors.initials: W
authors.lastname: Kanchanatawan
authors.affiliation: Department of Orthopedics, Lerdsin General Hospital, Bangkok, 10500, Thailand. ponrachaimd@gmail.com.
authors.forename: Ponrachai
authors.initials: P
authors.lastname: Wongthongsalee
mesh_terms: D000293:Adolescent; D000328:Adult; D001864:Bone Wires; D002968:Clavicle / Q000293:injuries* / Q000601:surgery; D005260:Female; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D055815:Young Adult
keywords: Clavicle nonunion; Coracoclavicular stabilization; Unstable distal clavicle fracture