I'm a second-year medical student at the University of Pittsburgh, and I'm presenting on behalf of my senior co-authors. These are our disclosures, and none are relevant to this talk. Single-plate fixation has been widely accepted as the preferred treatment option for displaced midshaft clavicle fractures, with constructs placed either superiorly or anteriorly, as shown here. However, recent studies have highlighted the high rates of secondary surgery associated with single-plate fixation, with re-operates up to 27%, largely driven by symptomatic implants. As a result, recent studies have advocated for the use of dual-plate fixation using two orthogonally-placed mini-fragments. Studies have shown that dual-plating may have biomechanical advantages and could potentially have lower rates of secondary surgery compared to single-plating. However, few studies have reliably compared re-operation rates and risk between dual, superior, and superior-plating specifically. Thus, the purpose of this study was to compare re-operation rates and re-operation risk among patients who underwent dual, superior, and anterior-plate fixation for displaced midshaft clavicle fractures. We also analyzed implant survival in each cohort. We hypothesized that dual-plate fixation would have a significantly lower re-operate and greater implant survival compared to both superior and anterior-plate fixation. This was a retrospective cohort study at a Level 1 trauma center from 2010 to 2021 of operatively-treated displaced midshaft clavicle fractures. We looked at three cohorts. The first was superior-plate fixation with a pre-contoured 3.5-millimeter small fragment. The second was anterior with a pre-contoured 3.5-millimeter small fragment. The third was dual-plate fixation with two orthogonally-placed mini-fragments ranging from 2 to 2.7 millimeters. We excluded pediatric patients and patients with over 6 weeks between injury and surgery, and a minimum of 12-month follow-up was employed. Here are radiographic examples of each construct with dual-plating shown here on the bottom. Preoperatively, we collected demographics, fracture pattern, and trauma mechanism. Our main outcomes were all-cause re-operation rate. We also looked at non-unions. Symptomatic implants were removed at the discretion of the surgeon based on surgeon-patient discussion. All surgeons in this study thoroughly discussed the risks of implant removal with the patient, advising them to only undergo removal if the implant was significantly interfering with quality of life or ADLs. Finally, multivariate multilevel mixed effects parametric survival models were used to assess re-operation risk measured via hazard ratios. For our results, we had 256 patients with 63 in the dual-plate, 101 in the superior, and 92 in the anterior. Mean follow-up was almost 5 years and mean age was 39 years. There were a mix of Z-type, oblique, and transverse fractures. As shown in this table, the dual-plating cohort was slightly older and had slightly less mean follow-up. Sex, BMI, smoking, diabetes, high energy trauma, and fracture morphology were similar across groups. There were 31 total re-operations among 22 patients, 1 in the dual-plating, 18 in the superior-plating, and 12 in the anterior-plating. There were 8 total non-unions, 0 in the dual-plating, 4 in the superior, and 4 in the anterior. The main indications for re-operation were symptomatic hardware, non-union, and infection. In our survival analysis, superior-plating had the highest re-operate followed by anterior and finally dual. A comparison of implant survival between overall single and dual-plating is shown on the left. A breakdown comparison of survival across superior, anterior, and dual is demonstrated in the figure on the right. After controlling for smoking status and fracture morphology, our model demonstrated that single-plating overall had 8 times greater risk of re-operation than dual-plating. More specifically, single superior-plating had 8 times greater risk of re-operation than dual-plating, whereas anterior-plating was not significantly different when compared to dual-plating. Dual-plate fixation represents an excellent treatment for displaced mid-shaft clavicle fractures with low rates of non-union and re-operation. When compared to single pre-contoured superior anterior-plate fixation, dual mini-fragment fixation had a nearly 8-fold lower risk of re-operation. This may potentially mitigate the concern that operative treatment of clavicle fractures is associated with a high risk of implant removal. Future randomized control trials are needed to compare dual and single-plate fixation techniques. There are a couple important limitations to this study. As a retrospective analysis, this study is subject to selection bias and confounding. Additionally, the dual-plating cohort had a slightly lower mean follow-up time. However, this study analyzed re-operation rate based on person years, which accounts for differences in follow-up. Another limitation is surgeon variability within the study, which could result in different counseling and threshold for implant removal and slightly varying postoperative rehab protocols. Future studies should utilize a randomized or prospective study design, incorporate a comparison to non-op cohorts, and assess patient-reported outcomes. Here are my references. And thank you for listening. �

dual-plate fixation

displaced midshaft clavicle fractures

re-operation rates

superior-plate fixation

anterior-plate fixation