Arthroscopically Assisted Fixation of Unstable Distal Third Clavicle Fractures

INTRODUCTION Clavicle fractures are common injuries, representing 35 to 45% of fractures of the shoulder girdle. Fifteen to 25% of those involve the distal portion of the clavicle. Previously, non-operative management of midshaft clavicle fractures was based on the premise that even grossly malunited fractures had a minimal impact on functional outcomes. However, level I evidence supports the idea that operative management of markedly displaced or shortened midshaft clavicle fractures can improve functional outcomes. The operative management of distal third clavicle fractures is similarly supported to improve shoulder function for displaced fractures. Neer classified distal clavicle fractures into three types. Type I fractures are lateral to the coracoclavicular ligaments. Type II fractures are medial to the coracoclavicular ligaments. Type II fractures are further subdivided into type A (coracoclavicular ligaments attached to the distal fragment) and type B (conoid ligament disrupted; trapezoid ligament remains attached to the distal fragment) (Figure 1). Type III fractures extend into the acromioclavicular (AC) joint. Overall, Type II distal clavicle fractures have a 20 to 30% nonunion rate if treated nonoperatively. Neer Type IIB fractures are especially problematic due to the location of the fracture between the coracoclavicular ligaments. Displacement of the fracture is enhanced by the weight of the arm, muscle forces, and disruption of the vertical restraint of the medial fragment. Because of these factors, Type IIB fractures are likely to progress to nonunion or malunion. Initial surgical management of Type IIB fractures has been proposed to encourage properly aligned healing and maximize functional outcomes. Currently, there is no surgical standard that provides anatomic fracture fixation, restoration of the superiorinferior and anterior-posterior fracture stability, avoidance of symptomatic hardware, and minimal surgical dissection. Surgical techniques include open reduction and internal fixation with subacromial hook-plates, percutaneous wires, coracoclavicular screws, cerclage wires, unlocked and pre-contoured locked plates, and coracoclavicular ligament reconstruction techniques using various suture materials or tendon grafts with or without excision of the distal fragment. Arthroscopically assisted fixation techniques have been recently described, as well. In this paper we present the short to midterm results of arthroscopically assisted fixation of Type IIB distal clavicle fractures using the TightRope system (Arthrex; Naples, FL). This minimally invasive technique accomplishes the essential principles of treating this unique fracture pattern including: anatomic fracture alignment; restoration of superior-inferior and anterior-posterior ligamentous stability; and fracture compression.