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Case report

Stabilization of neer iib type distal clavicle fracture using the tightrope system – case report

Dejan Aleksandrić1, Lazar Mičeta1,2, Bojana Aleksić1, Uroš Dabetić3, Jovana Grupković3
  • Institute for Orthopedics Banjica, Belgrade, Serbia
  • University of Belgrade, Faculty of Medicine, Belgrade, Serbia
  • University Clinical Center of Serbia, Clinic for Orthopedic Surgery and Traumatology, Belgrade, Serbia

ABSTRACT

Introduction: Fractures of the distal end of the clavicle account for 10% – 30% of all fractures of this bone, however, they account for as many as 50% of nonunions and malunions in clavicle fractures. Of all distal clavicle fractures, the highest percentage of complications appertain to Neer type IIB fractures. The aim of this paper is to describe the case of a female patient with a Neer type IIB clavicle fracture treated by fracture reduction and flexible stabilization of the coracoclavicular joint using the TightRope system.

Case report: A 48-year-old female patient, injured in a traffic accident while driving a car, suffered a Neer type IIB fracture of the distal edge of the left clavicle. Three days after the injury, the patient underwent indirect stabilization surgery of the coracoclavicular joint by fixation, with the application of the TightRope system. Rehabilitation began on the first postoperative day and was completed three months after surgery, with the achievement of full range of motion in the left shoulder, return of muscle tone and strength of the shoulder muscles, followed by a return to everyday life and work activities, as before the injury.

Conclusion: Although no gold standard exists in the operative treatment of the above-described injuries, the indirect method of stabilization and flexible fixation of the coracoclavicular joint, using different types of sutures, achieves good to excellent results. Comparing this method with other described techniques indicates that it has a better functional result, which is achieved faster with a lower complication rate. Our patient's functional results contribute to literature data and yet again demonstrate the effectiveness of this type of treatment for these complex injuries.


INTRODUCTION

Fractures of the distal end of the clavicle account for 10% – 30% of all fractures of this bone, and are the second most common fractures, after diaphyseal fractures [1],[2],[3]. At the same time, they have the greatest frequency of non-unions and malunions – as many as 50% [1],[4]. Neer type IIB fractures are defined as fractures in the region of the coracoclavicular (CC) ligament wherein the conoid segment of the CC ligament is disrupted and there is a dislocation of the proximal fragment [1],[5].

In the younger population, the mechanism of injury is, in most cases, direct impact of force, usually as the result of traffic traumatism, fall from a height, or as the result of sports activities, while in older patients, the impact of low-intensity force is more common [5].

The treatment of Neer type IIB fractures of the distal end of the clavicle is most commonly surgical, primarily due to the high incidence of non-union and malunion in patients treated non-surgically [1],[5]. Currently, there is no gold standard regarding the surgical technique for this type of fracture, rather, surgical techniques are, according to the concept of fixation, divided into the following two groups: direct osteosynthesis of the clavicle (with the application of various plates, screws and intramedullary nails) and indirect stabilization of the fracture through fixation of the CC joint (with the use of various systems of rigid or flexible fixation) [1],[6],[7].

According to the available literature data, the outcomes of all types of surgical treatment have proven to be predominantly satisfactory, with an emphasis on the advantages of the application of indirect flexible fixation, as a technically less challenging and often less invasive surgical technique, with shorter operative time, better esthetic outcomes, lower treatment costs, as well as the fact that a second surgical procedure and removal of the implant are not necessary [1],[2],[8],[9].

The aim of this study is to present the case of a female patient with a Neer type IIB distal clavicle fracture, which was surgically treated with indirect flexible fixation using the AC TightRope® (Arthrex, Naples, Florida, USA) system, as well as to present the results of the patient’s early postoperative recovery.

CASE REPORT

A 48-year-old female patient came to our hospital due to injury to her left shoulder, which she sustained in a traffic accident while driving a car. She presented with pain and limited movement in the left shoulder, with a deformity in the region of the left acromioclavicular (AC) joint. The neurological and vascular findings regarding the injured arm were normal. Standard radiographs were performed and a Neer type IIB left distal clavicle fracture was confirmed (Figure 1). Other injuries and diseases were excluded.

Figure 1. Preoperative AP radiograph of the left shoulder demonstrating the Neer type IIB fracture of the distal end of the clavicle

Figure 1. Preoperative AP radiograph of the left shoulder demonstrating the Neer type IIB fracture of the distal end of the clavicle

For the purpose of assessing shoulder function, range of movement, and level of pain, the Constant Shoulder Score (CSS) was applied, and, at admission, the score was 12/100 [10],[11]. On the third day after injury, the patient was surgically treated with indirect stabilization of the CC joint, i.e., with fixation using the AC TightRope® system.

The surgical procedure was performed in general anesthesia upon placing the patient in the beach chair position. A mini-incision superior approach was made to the distal clavicle, an oblique fracture of the distal clavicle was noted, with propagation of the crack at the level of the CC ligament, with complete rupture of the conoid ligament, preserved function of the trapezoid ligament, and a stable AC joint.

First, the fracture was stabilized with a K-wire in the direction of the position of the planned fixation system. Next, with the help of the wire, a cannulated drill, U cilju evaluacije funkcionalnog stanja zgloba ra- measuring 4 mm in diameter, was inserted and a bone tunnel was made from the distal end of the proximal fragment of the clavicle to the inferior cortex of the coracoid process of the scapula. After this, a guiding wire was introduced through the cannulated drill and was used to guide the “end button” system to the inferior cortex of the coracoid process. After the button was guided through the inferior cortex of the coracoid process, the fracture was reduced with fluoroscopy control, and finally, additional tightening and fixation of the system was carried out by tying the sutures (Figure 2). The surgical wound was closed in the standard fashion.

Figure 2. Intraoperative AP radiograph of the left shoulder showing initial adequate reduction and fixation of the fracture

Figure 2. Intraoperative AP radiograph of the left shoulder showing initial adequate reduction and fixation of the fracture

Early postoperative recovery was uneventful, without any local or systemic complications. Desault’s immobilization was initially applied, for the purpose of better postoperative pain management, and was, after one day, replaced with an orthosis, in the form of a mitella, which supports the arm and enables partial movement of the surgically treated shoulder. On the first postoperative day, the patient was included in an early rehabilitation program, wherein she started with intermittent pendulum exercises, with restricted elevation and flexion of the surgically treated shoulder over 90 degrees during the following six weeks. The patient was kept for in-hospital treatment for four days, for the purpose of carrying out physical therapy and following-up the course of the initial rehabilitation.

The first outpatient follow-up was performed on the fourteenth day after the operation, when the sutures were removed. The surgical wound healed per primam, without any complications. The range of movement in the left shoulder was limited, with a flexion amplitude of 45°, an extension amplitude of 10°, an abduction amplitude of 40°, and an amplitude of external rotation of 10°. The CSS at first follow-up was 37/100.

The second follow-up was six weeks after the operation, with observed further clinical progress during rehabilitation, an increase of the range of movement, with an amplitude of flexion of 45°, an amplitude of extension of 10°, an amplitude of abduction of 40°, and an amplitude of external rotation of 10°, as well as with an improvement of the CSS, which was, at the time, 62/100. Follow-up radiography showed the presence of sings of fracture healing in unchanged position (Figure 3a).

Figure 3. Postoperative AP radiographs of the left shoulder: a) 14 days after the surgery; b) six weeks after surgery

Figure 3. Postoperative AP radiographs of the left shoulder: a) 14 days after the surgery; b) six weeks after surgery

During the first two postoperative weeks, the arm was immobilized with an orthosis, which the patient removed only during physical therapy. During the following four weeks, she wore the orthosis occasionally, after which the orthosis was completely removed.

The patient completed rehabilitation three months after surgery, achieving a full range of motion in her left shoulder, the recovery of the shoulder muscle tone and strength, and a CSS score of 86/100, enabling her to fully return to her everyday activities, as before the injury. A follow-up X-ray, three months after surgery, showed healing of the fracture in unchanged position, with preserved congruency of the AC joint (Figure 3b). Clinical follow-up of the patient was continued for the following four months during which there was no change in the clinical finding nor any development of subjective complaints, with the last recorded CSS of 92/100, four months after surgery.

DISCUSSION

Fractures of the distal third of the clavicle are characterized by CC ligament rupture with a dislocation of the proximal fragment upwards, which leads to significant instability of the AC joint and is one of the reasons for frequent non-union of these fractures, especially in the case of non-surgically treated patients [1],[4],[9].

Historically speaking, the main method of treating these fractures was immobilization, until the publishing of the study by Charles Neer, in 1960, which indicated that the rupture of the CC ligament affected the frequency of mal-unions and non-unions in these fractures [12],[13].

The modern approach to non-surgical treatment of this injury envisages immobilization if the injured shoulder with a mitella or a figure of eight bandage, for a period of 2 – 4 weeks, as well as multi-step physical therapy [14]. However, this type of treatment is applied only when the fragments of the fractured bone are not dislocated or are minimally dislocated, i.e., in patients whose risk regarding surgery is unacceptably high [15].

However, literature shows that instability and a significant degree of fragment dislocation are frequent in this type of injury, which is why the authors mostly agree that Neer type IIB fractures should primarily be treated surgically, with one of the fixation techniques [1],[5],[7],[12],[15].

According to the concept of fixation applied, surgical techniques described in literature can roughly be divided into the following two groups: (1) direct osteosynthesis of the clavicle and (2) indirect fracture stabilization by CC ligament fixation [1],[7],[16]. None of the described numerous surgical techniques belonging to one of the abovementioned groups did not prove to be absolutely superior to the others [7],[17].

Direct osteosynthesis can be performed with the use of different types of plates: with a standard precontoured plate for the distal clavicle, with a hook plate, or, less frequently, with an anatomical plate for the diaphysis of the clavicle, or an anatomical plate for the distal radius [16],[18]. Less frequently, osteosynthesis is performed with screws, K-wires, and intramedullary nails [7],[19],[20].

Osteosynthesis of a Neer type IIB fracture with an anatomical plate and screws has shown good results [21]. It has been shown that good stability at the site of the fracture is achieved with this technique, while intraoperative manipulation of the implant is simple [18],[22]. On the other hand, the technique is connected to numerous complications, primarily to damage and impingement of the rotator cuff, to acromial “osteolysis”, as well as to irritation of the skin above the implant and the possibility of its rupture [18],[22].

In literature, the need for a second surgical procedure and the removal of the implant after the fracture has healed, has been reported as the main drawback of direct osteosynthesis [17],[19]. Seo et al. stress that it is necessary to perform revision surgery and remove the implant material three months after the initial operation, in case a hook plate is used, which increases the possibility of complications as well as the costs of treatment [17]. The possibility of the fragments being moved by the hook of the plate as well as the possibility of damage to the surrounding soft tissue, especially the nerve structures, while the plate is being removed, which may lead to the reduction of sensitivity in this region, has been pointed out in literature [16],[17],[23].

In addition to the application of plates and screws, this fracture can be stabilized with K-wires, the Knowles nail, and the tension band system. However, these techniques have predominantly been abandoned due to a large number of complications, primarily in the form of fracture non-union and migration of the wires into internal organs [20].

As an alternative to osteosynthesis of the clavicle, another modern approach to treating this injury is also described – isolated fixation of the CC joint, more precisely reparation of the damaged conoid segment of the CC ligament with the help of rigid or flexible materials [24].

Jin et al. monitored 17 patients with distal clavicle fracture and CC ligament rupture treated with CC joint stabilization, with the use of cannulated screws, and emphasized the stability achieved at the site of the fracture as the main advantage, along with the possibility of early start of rehabilitation [19].

However, this technique showed its drawbacks very early on. These are reflected primarily in the possible achievement of a lesser range of motion, in the need for a new operation for the purpose of extracting the screw after union is achieved, as well as in possible loosening of the screw before the fracture has healed [19],[24]. The desire to eliminate these shortcomings of indirect fixation with a screw, and at the same time keep all the benefits, resulted in the application of flexible indirect fixation [1],[8],[9],[19],[25],[26]. The use of the AC TightRope® system has proven to be the method of choice, with multiple reports confirming good postoperative outcomes [1],[8],[9],[26].

Soh et al. were pioneers in this area of orthopedic surgery demonstrating that the TightRope system, despite its obviously lesser invasiveness, as compared to other methods, is indeed adequate for achieving the appropriate stability of the fracture, enabling early commencement of rehabilitation [9].

In their cohort study, Al-Tawil et al. later confirmed the hypotheses on the benefits of TightRope system application, and at the same time recorded a small number of early complications, as well as the complete absence of intraoperative complications [1].

Additional benefits of this method, as compared to direct osteosynthesis, are a lesser intraoperative loss of blood, shorter operative time, and a smaller surgical incision with an esthetically acceptable outcome [27],[28]. Complications, such as infections, non-union, migration of the suture or suture rupture, have been described in literature, and sometimes they require a second surgical procedure, however, generally speaking, they are rare [9],[20],[26],[27].

In the case of our patient, there were no complications, and, within a short time after surgery, the patient regained full range of movement and full function of the injured shoulder, returning to her normal everyday activities, as before the injury.

In addition to using isolated flexible indirect fracture fixation, combined techniques of fracture stabilization with a plate and screws, with additional stabilization of the CC joint, are also widely in use. Xu et al. compared two groups of patients treated with direct osteosynthesis of the fracture with the use of a plate and with a combination of a plate and a suture anchor, concluding that a combination of these methods yields a better result as it provides more stable fixation at the site of the fracture [25]. The authors, however, also point out the drawbacks of this technique, primarily greater trauma to the surrounding tissues, increased cost of treatment, and the frequent need for a new procedure and removal of the plate [25].

However, the results of numerous studies have shown that the use of a combination of these two methods, as opposed to isolated flexible fixation, does not yield better results at the end of treatment [8],[17],[25]. In both approaches, satisfactory stability of the joint and full range of movement is achieved in patients [1],[5],[8],[16],[19],[25]. The advantage is, in fact, given to isolated flexible fixation, primarily due to the shorter time period needed for full rehabilitation and a greater overall satisfaction of the patients [16],[17],[19],[23],[25].

An additional step towards reducing invasiveness, when stabilizing a fracture of the distal clavicle, is indirect fixation of the CC joint with the TightRope system, using minimally invasive, arthroscopic shoulder surgery, thereby additionally shortening the time of hospital stay, as well as recovery time [26],[29]. The drawbacks, on the other hand, are the complexity of the surgical technique, which requires a highly skilled surgeon, prolonged operative time, and increased treatment costs. Nevertheless, bearing in mind its advantages, an increasingly wider application of this technique may be expected [24],[30].

CONCLUSION

The surgical methods for threating the above-described fractures have been categorized into two broad groups: (1) direct osteosynthesis of the clavicle and (2) indirect osteosynthesis through the stabilization of the CC joint, primarily with different types of sutures. Although there is no gold standard in the surgical treatment of these injuries, according to literature data, the results of treatment carried out by applying the method of indirect flexible stabilization of the CC joint are good to excellent. Comparison of this method with other described techniques indicates that it achieves a better functional result, which is accomplished more quickly, and with lesser complications, and as especially significant, without the need for a second surgical procedure, which undoubtedly decreases treatment costs and shortens the operative theater time – this, in modern clinical practice, has become an increasingly important parameter to be considered when choosing the surgical technique. The functional results of our patient contribute to the literature data, and yet again, demonstrate the effectiveness of this form of treatment of these complex injuries.

  • Conflict of interest:
    None declared.

Informations

Volume 4 No 1

March 2023

Pages 89-97
  • Keywords:
    distal clavicle, fractures, internal fixation of fractures
  • Received:
    16 November 2022
  • Revised:
    27 November 2022
  • Accepted:
    28 November 2022
  • Online first:
    03 March 2023
  • DOI:
  • Cite this article:
    Aleksandrić D, Mičeta L, Aleksić B, Dabetić U, Grupković J. Stabilization of Neer IIB type distal clavicle fracture using the Tightrope system: Case report. Serbian Journal of the Medical Chamber. 2023;4(1):89-97. doi: 10.5937/smclk4-41228
Corresponding author

Jovana Grupković
University Clinical Center of Serbia, Clinic for Orthopedic Surgery and Traumatology
Address: 2 Pasterova Street, 11000 Belgrade, Serbia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


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    2. Kihlström C, Möller M, Lönn K, Wolf O. Clavicle fractures: epidemiology, classification and treatment of 2 422 fractures in the Swedish Fracture Register; an observational study. BMC Musculoskelet Disord. 2017 Feb 15;18(1):82. doi: 10.1186/s12891-017-1444-1. [CROSSREF]

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REFERENCES

1. Al-Tawil K, Garner M, Antonios T, Karrupaiah K, Tahmassebi R, Colegate-Stone T, et al. The use of Tightrope device as the sole method of fixation in treating lateral end clavicle fractures. Shoulder Elbow. 2022 Feb;14(1):60-64. doi: 10.1177/1758573220964807. [CROSSREF]

2. Kihlström C, Möller M, Lönn K, Wolf O. Clavicle fractures: epidemiology, classification and treatment of 2 422 fractures in the Swedish Fracture Register; an observational study. BMC Musculoskelet Disord. 2017 Feb 15;18(1):82. doi: 10.1186/s12891-017-1444-1. [CROSSREF]

3. Asadollahi S, Bucknill A. Hook Plate Fixation for Acute Unstable Distal Clavicle Fracture: A Systematic Review and Meta-analysis. J Orthop Trauma. 2019 Aug;33(8):417-422. doi: 10.1097/BOT.0000000000001481. [CROSSREF]

4. Azar MF, Beaty HJ. Campbell's Operative Orthopaedics. 14th ed. Philadelphia, PA, USA: Elsevier Inc; 2020.

5. Stenson J, Baker W. Classifications in Brief: The Modified Neer Classification for Distal-third Clavicle Fractures. Clin Orthop Relat Res. 2021 Jan 1;479(1):205-209. doi: 10.1097/CORR.0000000000001456. [CROSSREF]

6. Hislop P, Sakata K, Ackland DC, Gotmaker R, Evans MC. Acromioclavicular Joint Stabilization: A Biomechanical Study of Bidirectional Stability and Strength. Orthop J Sports Med. 2019 Apr 17;7(4):2325967119836751. doi: 10.1177/2325967119836751. [CROSSREF]

7. Sambandam B, Gupta R, Kumar S, Maini L. Fracture of distal end clavicle: A review. J Clin Orthop Trauma. 2014 Jun;5(2):65-73. doi: 10.1016/j.jcot.2014.05.007. [CROSSREF]

8. Flinkkilä T, Heikkilä A, Sirniö K, Pakarinen H. TightRope versus clavicular hook plate fixation for unstable distal clavicular fractures. Eur J Orthop Surg Traumatol. 2015 Apr;25(3):465-9. doi: 10.1007/s00590-014-1526-9. [CROSSREF]

9. Soh C, Sivapathasundaram N, Parthiban R, Ramanand A. A technique of distal clavicle fracture fixation using the tightrope procedure. Malays Orthop J. 2011 Nov;5(3):20-3. doi: 10.5704/MOJ/1111.002. [CROSSREF]

10. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987 Jan;(214):160-4.

11. Fabre T, Piton C, Leclouerec G, Gervais-Delion F, Durandeau A. Entrapment of the suprascapular nerve. J Bone Joint Surg Br. 1999 May;81(3):414-9. doi: 10.1302/0301-620x.81b3.9113. [CROSSREF]

12. Stenson J, Baker W. Classifications in Brief: The Modified Neer Classification for Distal-third Clavicle Fractures. Clin Orthop Relat Res. 2021 Jan 1;479(1):205-209. doi: 10.1097/CORR.0000000000001456. [CROSSREF]

13. NEER CS 2nd. Nonunion of the clavicle. J Am Med Assoc. 1960 Mar 5;172:1006- 11. doi: 10.1001/jama.1960.03020100014003. [CROSSREF]

14. Hall JA, Schemitsch CE, Vicente MR, Dehghan N, Nauth A, Nowak LL, et al; Canadian Orthopaedic Trauma Society (COTS). Operative Versus Nonoperative Treatment of Acute Displaced Distal Clavicle Fractures: A Multicenter Randomized Controlled Trial. J Orthop Trauma. 2021 Dec 1;35(12):660-666. doi: 10.1097/BOT.0000000000002211. [CROSSREF]

15. Buckley RE, Moran CG, Apivatthakakul T. AO principles of fracture management. Davos Platz, Switzerland: AO Foundation; 2017.

16. Hohmann E, Hansen T, Tetsworth K. Treatment of Neer type II fractures of the lateral clavicle using distal radius locking plates combined with TightRope augmentation of the coraco-clavicular ligaments. Arch Orthop Trauma Surg. 2012 Oct;132(10):1415-21. doi: 10.1007/s00402-012-1570-z. [CROSSREF]

17. Seo JB, Kwak KY, Yoo JS. Comparative analysis of a locking plate with an all-suture anchor versus hook plate fixation of Neer IIb distal clavicle fractures. J Orthop Surg (Hong Kong). 2020 Sep-Dec;28(3):2309499020962260. doi: 10.1177/2309499020962260. [CROSSREF]

18. Kashii M, Inui H, Yamamoto K. Surgical treatment of distal clavicle fractures using the clavicular hook plate. Clin Orthop Relat Res. 2006 Jun;447:158-64. doi: 10.1097/01.blo.0000203469.66055.6a. [CROSSREF]

19. Jin CZ, Kim HK, Min BH. Surgical treatment for distal clavicle fracture associated with coracoclavicular ligament rupture using a cannulated screw fixation technique. J Trauma. 2006 Jun;60(6):1358-61. doi: 10.1097/01. ta.0000220385.34197.f9. [CROSSREF]

20. Gutman MJ, Joyce CD, Patel MS, Lazarus MD, Horneff JG. Outcomes Following Different Fixation Strategies of Neer Type IIB Distal Clavicle Fractures. Arch Bone Jt Surg. 2022 Feb;10(2):160-165. doi: 10.22038/ABJS.2021.54472.2718. [CROSSREF]

21. Teimouri M, Ravanbod H, Farrokhzad A, Sabaghi J, Mirghaderi SP. Comparison of hook plate versus T-plate in the treatment of Neer type II distal clavicle fractures: a prospective matched comparative cohort study. J Orthop Surg Res. 2022 Jul 30;17(1):369. doi: 10.1186/s13018-022-03261-8. [CROSSREF]

22. Charity RM, Haidar SG, Ghosh S, Tillu AB. Fixation failure of the clavicular hook plate: a report of three cases. J Orthop Surg (Hong Kong). 2006 Dec;14(3):333-5. doi: 10.1177/230949900601400320. [CROSSREF]

23. Wang L, Ang M, Lee KT, Naidu G, Kwek E. Cutaneous hypoesthesia following plate fixation in clavicle fractures. Indian J Orthop. 2014 Jan;48(1):10-3. doi: 10.4103/0019-5413.125478. [CROSSREF]

24. Kim DW, Kim DH, Kim BS, Cho CH. Current Concepts for Classification and Treatment of Distal Clavicle Fractures. Clin Orthop Surg. 2020 Jun;12(2):135-144. doi: 10.4055/cios20010. [CROSSREF]

25. Xu H, Chen WJ, Zhi XC, Chen SC. Comparison of the efficacy of a distal clavicular locking plate with and without a suture anchor in the treatment of Neer IIb distal clavicle fractures. BMC Musculoskelet Disord. 2019 Oct 30;20(1):503. doi: 10.1186/s12891-019-2892-6. [CROSSREF]

26. Zheng YR, Lu YC, Liu CT. Treatment of unstable distal-third clavicule fractures using minimal invasive closed-loop double endobutton technique. J Orthop Surg Res. 2019 Jan 31;14(1):37. doi: 10.1186/s13018-019-1073-5. [CROSSREF]

27. Chen CY, Yang SW, Lin KY, Lin KC, Tarng YW, Renn JH, et al. Comparison of single coracoclavicular suture fixation and hook plate for the treatment of acute unstable distal clavicle fractures. J Orthop Surg Res. 2014 May 29;9:42. doi: 10.1186/1749-799X-9-42. [CROSSREF]

28. Nie S, Li HB, Hua L, Tang ZM, Lan M. Comparative analysis of arthroscopic-assisted Tight-rope technique and clavicular hook plate fixation in the treatment of Neer type IIB distal clavicle fractures. BMC Musculoskelet Disord. 2022 Aug 6;23(1):756. doi: 10.1186/s12891-022-05724-9. [CROSSREF]

29. Pandya NK, Hosalkar HS, Babatunde OM, Huffman GR. Distal third clavicular fracture fixation: A new arthroscopically-assisted technique. Current Orthopaedic Practice. 2009;20(4):454–7. [CROSSREF]

30. Loriaut P, Moreau PE, Dallaudière B, Pélissier A, Vu HD, Massin P, et al. Outcome of arthroscopic treatment for displaced lateral clavicle fractures using a double button device. Knee Surg Sports Traumatol Arthrosc. 2015 May;23(5):1429-33. doi: 10.1007/s00167-013-2772-9. [CROSSREF]

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5. Stenson J, Baker W. Classifications in Brief: The Modified Neer Classification for Distal-third Clavicle Fractures. Clin Orthop Relat Res. 2021 Jan 1;479(1):205-209. doi: 10.1097/CORR.0000000000001456. [CROSSREF]

6. Hislop P, Sakata K, Ackland DC, Gotmaker R, Evans MC. Acromioclavicular Joint Stabilization: A Biomechanical Study of Bidirectional Stability and Strength. Orthop J Sports Med. 2019 Apr 17;7(4):2325967119836751. doi: 10.1177/2325967119836751. [CROSSREF]

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8. Flinkkilä T, Heikkilä A, Sirniö K, Pakarinen H. TightRope versus clavicular hook plate fixation for unstable distal clavicular fractures. Eur J Orthop Surg Traumatol. 2015 Apr;25(3):465-9. doi: 10.1007/s00590-014-1526-9. [CROSSREF]

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12. Stenson J, Baker W. Classifications in Brief: The Modified Neer Classification for Distal-third Clavicle Fractures. Clin Orthop Relat Res. 2021 Jan 1;479(1):205-209. doi: 10.1097/CORR.0000000000001456. [CROSSREF]

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15. Buckley RE, Moran CG, Apivatthakakul T. AO principles of fracture management. Davos Platz, Switzerland: AO Foundation; 2017.

16. Hohmann E, Hansen T, Tetsworth K. Treatment of Neer type II fractures of the lateral clavicle using distal radius locking plates combined with TightRope augmentation of the coraco-clavicular ligaments. Arch Orthop Trauma Surg. 2012 Oct;132(10):1415-21. doi: 10.1007/s00402-012-1570-z. [CROSSREF]

17. Seo JB, Kwak KY, Yoo JS. Comparative analysis of a locking plate with an all-suture anchor versus hook plate fixation of Neer IIb distal clavicle fractures. J Orthop Surg (Hong Kong). 2020 Sep-Dec;28(3):2309499020962260. doi: 10.1177/2309499020962260. [CROSSREF]

18. Kashii M, Inui H, Yamamoto K. Surgical treatment of distal clavicle fractures using the clavicular hook plate. Clin Orthop Relat Res. 2006 Jun;447:158-64. doi: 10.1097/01.blo.0000203469.66055.6a. [CROSSREF]

19. Jin CZ, Kim HK, Min BH. Surgical treatment for distal clavicle fracture associated with coracoclavicular ligament rupture using a cannulated screw fixation technique. J Trauma. 2006 Jun;60(6):1358-61. doi: 10.1097/01. ta.0000220385.34197.f9. [CROSSREF]

20. Gutman MJ, Joyce CD, Patel MS, Lazarus MD, Horneff JG. Outcomes Following Different Fixation Strategies of Neer Type IIB Distal Clavicle Fractures. Arch Bone Jt Surg. 2022 Feb;10(2):160-165. doi: 10.22038/ABJS.2021.54472.2718. [CROSSREF]

21. Teimouri M, Ravanbod H, Farrokhzad A, Sabaghi J, Mirghaderi SP. Comparison of hook plate versus T-plate in the treatment of Neer type II distal clavicle fractures: a prospective matched comparative cohort study. J Orthop Surg Res. 2022 Jul 30;17(1):369. doi: 10.1186/s13018-022-03261-8. [CROSSREF]

22. Charity RM, Haidar SG, Ghosh S, Tillu AB. Fixation failure of the clavicular hook plate: a report of three cases. J Orthop Surg (Hong Kong). 2006 Dec;14(3):333-5. doi: 10.1177/230949900601400320. [CROSSREF]

23. Wang L, Ang M, Lee KT, Naidu G, Kwek E. Cutaneous hypoesthesia following plate fixation in clavicle fractures. Indian J Orthop. 2014 Jan;48(1):10-3. doi: 10.4103/0019-5413.125478. [CROSSREF]

24. Kim DW, Kim DH, Kim BS, Cho CH. Current Concepts for Classification and Treatment of Distal Clavicle Fractures. Clin Orthop Surg. 2020 Jun;12(2):135-144. doi: 10.4055/cios20010. [CROSSREF]

25. Xu H, Chen WJ, Zhi XC, Chen SC. Comparison of the efficacy of a distal clavicular locking plate with and without a suture anchor in the treatment of Neer IIb distal clavicle fractures. BMC Musculoskelet Disord. 2019 Oct 30;20(1):503. doi: 10.1186/s12891-019-2892-6. [CROSSREF]

26. Zheng YR, Lu YC, Liu CT. Treatment of unstable distal-third clavicule fractures using minimal invasive closed-loop double endobutton technique. J Orthop Surg Res. 2019 Jan 31;14(1):37. doi: 10.1186/s13018-019-1073-5. [CROSSREF]

27. Chen CY, Yang SW, Lin KY, Lin KC, Tarng YW, Renn JH, et al. Comparison of single coracoclavicular suture fixation and hook plate for the treatment of acute unstable distal clavicle fractures. J Orthop Surg Res. 2014 May 29;9:42. doi: 10.1186/1749-799X-9-42. [CROSSREF]

28. Nie S, Li HB, Hua L, Tang ZM, Lan M. Comparative analysis of arthroscopic-assisted Tight-rope technique and clavicular hook plate fixation in the treatment of Neer type IIB distal clavicle fractures. BMC Musculoskelet Disord. 2022 Aug 6;23(1):756. doi: 10.1186/s12891-022-05724-9. [CROSSREF]

29. Pandya NK, Hosalkar HS, Babatunde OM, Huffman GR. Distal third clavicular fracture fixation: A new arthroscopically-assisted technique. Current Orthopaedic Practice. 2009;20(4):454–7. [CROSSREF]

30. Loriaut P, Moreau PE, Dallaudière B, Pélissier A, Vu HD, Massin P, et al. Outcome of arthroscopic treatment for displaced lateral clavicle fractures using a double button device. Knee Surg Sports Traumatol Arthrosc. 2015 May;23(5):1429-33. doi: 10.1007/s00167-013-2772-9. [CROSSREF]


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