title: A hybrid approach to mid-shaft clavicle fixation.
abstract: BACKGROUND
  The purpose of this study was to demonstrate the strength characteristics of a hybrid uni-cortical construct for clavicle fixation. The technique reported aims to combine benefits of uni-cortical fixation with stability comparable to traditional bi-cortical fixation. The approach utilises long, oblique uni-cortical screws at the distal ends of the plate acting as surrogate bi-cortical screws. Locked uni-cortical screws positioned centrally provide bending and torsion strength to the construct. This alternative hybrid uni-cortical technique does not require far cortex screw or drill penetration required in bi-cortical fixation techniques, thus avoiding potentially catastrophic vascular and or neurologic injury. The purpose of this study was to compare the mechanical behaviour of the hybrid uni-cortical construct to standard bi-cortical fixations under both torsion and bending loads.
  
  
  METHODS
  Thirty osteotomized human cadaveric clavicles were randomly allocated to three surgical fixation techniques: bi-cortical locked screw fixation, bi-cortical non-locked screw fixation and hybrid uni-cortical screw fixation. Each clavicle construct was tested non-destructively under torsional loading, and then under cantilever bending to failure. Construct bending and torsional stiffness, as well as ultimate failure strength, were measured.
  
  
  RESULTS
  There were no significant differences between uni-cortical or bi-cortical fixation constructs in either bending stiffness or ultimate bending moment (p>0.05); however, there was a trend towards greater bending stiffness in the hybrid construct. The uni-cortical hybrid fixation technique displayed a significantly lower mean torsional stiffness value when compared with the bi-cortical locked screw fixation (mean difference: 134.4 Nmm/degrees, 95% confidence interval [32.3, 236.4], p=0.007).
  
  
  CONCLUSIONS
  A hybrid uni-cortical approach to clavicle plate fixation that may improve screw purchase and reduce risk of intra-operative vascular damage demonstrates comparable bending strength to current bi-cortical approaches.
authors.affiliation: Department of Mechanical Engineering, University of Melbourne, Parkville, Victoria 3010, Australia.
authors.forename: Mathew
authors.initials: M
authors.lastname: Rawlings
authors.affiliation: Department of Orthopaedic Surgery, Epworth Healthcare, Richmond, Victoria 3121, Australia; Centre for Limb Reconstruction, The Epworth Centre, Richmond, Victoria 3121, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Knox
authors.affiliation: Department of Orthopaedic Surgery, Epworth Healthcare, Richmond, Victoria 3121, Australia; Centre for Limb Reconstruction, The Epworth Centre, Richmond, Victoria 3121, Australia; Department of Surgery, Southern Clinical School, Monash University, Clayton, Victoria 3168, Australia.
authors.forename: Minoo
authors.initials: M
authors.lastname: Patel
authors.affiliation: Department of Mechanical Engineering, University of Melbourne, Parkville, Victoria 3010, Australia. Electronic address: dackland@unimelb.edu.au.
authors.forename: David
authors.initials: D
authors.lastname: Ackland
mesh_terms: D001696:Biomechanical Phenomena; D001860:Bone Plates; D001863:Bone Screws; D002102:Cadaver; D002968:Clavicle / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000379:methods; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D008422:Materials Testing; D008954:Models, Biological; D011897:Random Allocation; D013718:Tensile Strength
keywords: Biomechanics; Clavicle fracture; Locking screw; Surgery; Vascular injury