title: Construct failure after open reduction and plate fixation of displaced midshaft clavicular fractures.
abstract: BACKGROUND
  Worldwide, implants mostly used for fixation of displaced midshaft clavicular fractures (DMCF) are the easily to bend reconstruction plate and the stiffer small fragment locking compression plate. Construct failure rates after plate fixation of DMCF are reported around 5 percent. Possible risk factors for construct failure are implant type and fracture type. However, little is known about the influence of fracture fixation method on construct failure. The aim of this study was to assess construct failure in plate fixation of DMCF and to identify possible risk factors.
  
  
  METHODS
  All consecutive patients treated in a level 1 trauma centre with open reduction and fixation of DMCF using a 3.5-mm reconstruction plate or 3.5-mm small fragment locking compression plate between 2007 and 2015 were evaluated. Potential risk factors for construct failure were analysed using univariate analysis.
  
  
  RESULTS
  Two hundred and fifty-nine patients were analysed. Fifty DMCF (19%) were fixated with a reconstruction plate and 209 (81%) with a small fragment locking compression plate. Construct failure was seen in 18 patients (6.9%), including 5 broken plates and 13 with screw loosening. Eight percent of all reconstruction plates broke in contrast to 0.5 percent of all small fragment locking compression plates (p=0.001). All broken implants were used as a bridging plate. Loosening of screws was seen in older patients and when the plate was fixated with less than three bicortical screws on one side of the fracture (p=0.002).
  
  
  CONCLUSIONS
  Overall construct failure after open reduction and plate fixation of DMCF occurred in 6.9 percent. Risk factors for plate breakage were the use of a reconstruction plate and a bridging method for fracture fixation. Risk factors for screw loosening were an increasing patient age and plate fixation with less than three bicortical screws on one side of the fracture.
  
  
  CONCLUSIONS
  Based on the results of this study our recommendation is to use a small fragment locking compression plate for open reduction and internal fixation of DMCF. The surgeon should always strive to fixate the plate on both sides of the fracture with at least three bicortical screws.
authors.affiliation: Dept. of Surgery, St. Elisabeth Hospital, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands. Electronic address: m.meeuwis@etz.nl.
authors.forename: M A
authors.initials: MA
authors.lastname: Meeuwis
authors.affiliation: Dept. of Surgery, St. Elisabeth Hospital, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands.
authors.forename: A F
authors.initials: AF
authors.lastname: Pull Ter Gunne
authors.affiliation: Dept. of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
authors.forename: M H J
authors.initials: MH
authors.lastname: Verhofstad
authors.affiliation: Dept. of Surgery, St. Elisabeth Hospital, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands.
authors.forename: F H W M
authors.initials: FH
authors.lastname: van der Heijden
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001860:Bone Plates / Q000009:adverse effects; D001863:Bone Screws; D002968:Clavicle / Q000000981:diagnostic imaging / Q000293:injuries*; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000009:adverse effects* / Q000379:methods; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D011475:Prosthesis Failure; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult
keywords: Clavicular fractures; Construct failure; Locking compression plate; Reconstruction plate