title: Management of unstable distal third clavicle fractures: clinical and radiological outcomes of the arthroscopy-assisted conoid ligament reconstruction and fracture cerclage with sutures.
abstract: BACKGROUND
  Surgical treatment is indicated for the management of Neer type IIB fractures of the distal third of the clavicle. The aim of this study was to assess the clinical and radiological outcomes, in cases of unstable distal third clavicle fractures managed by means of an arthroscopy-assisted conoid ligament reconstruction and fracture cerclage with sutures.
  
  
  METHODS
  Nine patients with unstable distal third clavicle fractures (Neer type IIB) managed arthroscopically by means of a conoid ligament reconstruction and fracture cerclage with sutures, between 2008 and 2012, were included. The QoL was evaluated at the last follow-up visit, by means of the Health Survey questionnaire (SF36), the visual analogue scale (VAS) for pain, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the constant score, and a Global Satisfaction scale (from 0 to 10). The mean time from fracture fixation until radiological union, the development of hardware loosening, nonunion, infections, and hardware skin discomfort were evaluated.
  
  
  RESULTS
  The mean age was 36 [21-48] years old. The mean [range] time from surgery until the last follow-up visit was 49 [46-52] months. Values of the questionnaires assessed at the last follow-up visit were: (1) physical SF36 score (50.72 ± 6.88); (2) mental SF36 score (50.92 ± 11.65); (3) VAS for pain (1.86 ± 1.35); (4) DASH questionnaire (11.97 ± 7.03); (5) constant score (89.67 ± 8.55), and (6) Global Satisfaction (8.17 ± 0.98). The mean time elapsed from fracture fixation to radiological union was 8.41 ± 3.26 months. Hardware loosening was observed in none of the patients. Nonunion was observed in 11.11% (1/9) of the patients. Hardware skin discomfort was observed in 11.11% (1/9) of the patients.
  
  
  CONCLUSIONS
  Patients with unstable distal third clavicle fractures managed by means of an arthroscopy-assisted conoid ligament reconstruction and fracture cerclage with sutures may have good clinical and radiological outcomes, with no need for a second surgical procedure to remove any metal hardware.
  
  
  METHODS
  Therapeutic; case series, Level IV.
authors.affiliation: Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Street Sant Quintí 89, 08026, Barcelona, Spain. luisgerardonaterac@gmail.com.
authors.forename: Luis Natera
authors.initials: LN
authors.lastname: Cisneros
authors.affiliation: Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Street Sant Quintí 89, 08026, Barcelona, Spain.|Hospital Quirón Teknon, Street Vilana 12, 08022, Barcelona, Spain.
authors.forename: Juan Sarasquete
authors.initials: JS
authors.lastname: Reiriz
mesh_terms: D000328:Adult; D001182:Arthroscopy; D002968:Clavicle / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing; D050723:Fractures, Bone / Q000150:complications / Q000000981:diagnostic imaging / Q000534:rehabilitation / Q000601:surgery*; D005599:Fractures, Ununited / Q000000981:diagnostic imaging / Q000209:etiology; D006801:Humans; D016268:Internal Fixators / Q000009:adverse effects; D008023:Ligaments, Articular / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D059352:Musculoskeletal Pain / Q000209:etiology; D010147:Pain Measurement; D011788:Quality of Life; D011859:Radiography; D012189:Retrospective Studies; D013536:Suture Techniques; D013997:Time Factors; D055815:Young Adult
keywords: Arthroscopy assisted; Conoid ligament reconstruction; Fracture cerclage; Plate fixation; Unstable distal third clavicle fracture