Abstract
BACKGROUND:
Nonunion is a major concern for orthopedic surgeons, particularly nonunion of the clavicle, which can cause severe pain, loss of full range of motion, poor sleep quality, and loss of strength in the affected individuals. Platelet-rich plasma (PRP), an important biological agent, is widely used in orthopedics.
OBJECTIVE:
We used a combination of three techniques – the PRP technique, autologous bone grafting technique, and internal plate fixation technique – to ensure adequate internal fixation and enable a bone growth-supportive environment at the fracture site.
METHODS:
The surgical approach was applied to a patient with clavicle nonunion.
RESULTS:
Based on postoperative follow-up findings and intraoperative findings at the time of re-removal of the patient’s implant, the prognosis at the fracture site was considered satisfactory.
CONCLUSION:
We observed that the patient treated with this method had favorable clinical outcomes, and we recommend that this technique be used in patients with long-bone nonunion.
Introduction
Fractures of the clavicle are reportedly common and mostly localized to the midshaft followed by the lateral end [1]. Although most fractures heal, the incidence of midshaft nonunion after nonoperative and surgical treatment is 23.1%–31% and 2.4%–5.9%, respectively [2]. Individuals with clavicular nonunion may have pain, reduced full range of motion, poor-sleep quality, reduced strength, crepitation and cosmetic deformity [3, 4].
Currently, clavicular nonunion is a major concern for orthopedic doctors. However, currently, there are many approaches to resolve clavicular nonunion, such as modified Hagie intramedullary pin and autologous bone grafting, mersilene tape, and open reduction and plate fixation. Modified Hagie intramedullary pin and autologous bone grafting achieves strong internal fixation using bone tamponade at the fracture site. However, the use of an intramedullary pin is a surgically challenging step. In addition, in some patients having undergone this procedure, uncomfortable tender bursa has been found in the acromial position of the patients [5]. Internal plate fixation is the traditional approach to treat nonunion; however, it still has a high risk of postoperative nonunion [6].
Platelet-rich plasma is an important biological agent and is widely used in orthopedics [7]. It is an autologous blood-derived concentrate of platelets, which are a source of growth factors, interleukins, and other cytokines [8]. Many bioactive proteins are located in platelet alpha granules, which aid in tissue repair and hemostasis when released [9]. Qureshi et al. [10] examined 10 different human samples and discovered 1,507 distinct proteins in platelets. Therefore, platelet-rich plasma (PRP) is a bioactive autogenetic library that promotes tissue healing and regeneration [11]. The potential regenerative effect of PRP makes it an avenue of great interest in orthopedics [12].
We herein combined the PRP technique, autologous bone grafting technique, and internal plate fixation technique to treat clavicular nonunion.
Technique
The technique comprises the following steps. PRP was prepared by standard techniques before operation. Intraoperatively, relevant treatment was performed at the fracture site, and then, cancellous bone was obtained from the medial version of the anterior superior iliac ridge. Autologous bone grafting and internal plate fixation were performed at the fracture site.
PRP preparation
Step 1: The blood was collected from the patient and centrifuged for a short time at low centrifugal force (soft spin, 1500 rpm for 5 min) in the presence of an anticoagulant. The soft spin resulted in the formation of three distinct layers. From bottom to top, the layers were as follows: (i) red blood cell (RBC) layer, (ii) the “buffy coat” (BC) layer, and (iii) the platelet-poor plasma (PPP) layer. The BC layer is typically whitish and has the majority of platelets and leukocytes. Step 2A: To obtain pure PRP (P-PRP), PPP and the superficial BC were transferred to another tube for centrifugation at high centrifugal force (hard spin, 3200 g for 4 min). After this step, most of the PPP layer contents were discarded, and most of the leukocytes were not collected. The final P-PRP concentrate comprised an undetermined fraction of BC with a large number of platelets suspended in some fibrin-rich plasma. Step 2B: Herein, PPP, the entire BC layer, and some residual RBCs were transferred to another tube for producing leukocyte-rich PRP (L-PRP). The PPP was discarded after a round of hard-spin centrifugation (3400 g for 5 min). The final L-PRP contained the entire BC with the majority of the platelets, leukocytes, and the residual RBCs suspended in some fibrin-rich plasma.
Treatment of the fracture site
The soft tissue remaining at the site of the fracture was cleaned until blood appeared at the bone site of the fracture. Before moving on to the next step, the bleeding was stopped using a gauze. For autologous bone grafting, we used the cancellous bone of the medial plate at the position of the anterior superior iliac ridge; this would preserve both the quality of life of the patient and the aesthetic appearance of the surgical site. Then, we applied a full bone graft to the fracture; this was a 2-mm-thick full bone graft over the primary cortex. For internal plate fixation, appropriate plates were selected and adequate internal fixation was ensured. Finally, the prepared PRP was injected into the fracture site.
Case presentation
In September 2020, a 33-year-old man came to our outpatient clinic for open reduction and internal fixation of a clavicular fracture. In April 2019, the patient sustained right clavicle fracture and was treated with plate fixation. The plate broke because of nonunion 3 months later. The local doctors fixed the fracture with a longer plate and autologous bone grafting; however, even after 14 months, bone union could not be achieved. Thus, the patient visited our hospital. Figure. 1A and B show nonunion imaging results. Imaging showed discontinuity of the right clavicle cortex, and a defect was intraoperatively observed at the fracture end (Fig. 1C). Soft tissues at the site of the fracture were intraoperatively removed, and the autologous bone grafting technique, PRP technique, and internal plate fixation were the techniques used during the course of the treatment (Fig. 1D). Postoperative fluoroscopy of the fracture revealed good end-to-end alignment (Fig. 2A).
A and B show postoperative nonunion imaging of the clavicular fracture. C shows discontinuity of the right clavicle cortex, and a defect was intraoperatively observed at the fracture end. D shows the PRP technique, autograft technique, and plate internal fixation technique being used to treat clavicular fracture nonunion.
A. Postoperative fluoroscopy imaging shows good fracture end alignment. B. X-ray imaging performed 3 months postoperatively revealed good continuous alignment of the clavicular cortex. At the 20-month follow-up, we acquired X-ray images (C) and performed three-dimensional construction of the affected side (D) after the patient underwent removal of internal fixation.
During physical examination at the three-month postoperative follow-up, the patient reported no evident pain in the operated area, and imaging examination revealed good continuous alignment of the clavicular cortex (Fig. 2B). At the 20-month follow-up, the patient showed normal motor function. The patient requested removal of the internal plate fixation; we intraoperatively found that the lesion had healed well and removed the internal plate fixation. After surgery, we acquired X-ray images and performed three-dimensional construction of the affected side (Fig. 2C and D), and the findings showed that this method had a significant positive effect on clavicular nonunion.
This study was approved by the Ethics Committee of the First Hospital of Jilin University, Changchun, China. Written informed consent to use the clinical data and images was obtained from the included patient.
Daniilidis et al. [13] reported that midshaft clavicle fractures account for
Long-bone nonunion imposes a substantial burden to the patient, with pain, loss of function, and psychological distress as commonly encountered issues. In clinical practice, nonunion is most commonly associated with long-bone fractures of the forearm, humerus, tibia, clavicle, and femur [14]. However, the soft tissue covering the clavicle surface is relatively less and involved in the composition of the shoulder joint; therefore, it is essential to devise an appropriate surgical treatment plan to treat nonunion resulting from a clavicle fracture.
Recently, numerous studies have been reported on resolving clavicular nonunion [15, 16]. Yetter et al. [17] reported that plating results in reliable outcomes, whereas bone graft is likely to translate into a higher incidence of complications and reoperations. To our knowledge, treatment methods for clavicular nonunion after revision operation with internal plate fixation and autologous bone grafting have not been reported.
In this article, we describe a relatively novel surgical approach to treat clavicular nonunion after revision operation using autologous bone grafting and PRP technology. Platelets in PRP co-function with fibrin to form a hematoma during the inflammatory stage of bone healing and secrete a large number of cytokines to activate callus formation and consequently promote bone growth at the fracture site [18]. The autologous bone grafting plays the role of an osteoconductive, osteoinductive, and osteogenic substrate that can be used to cover bone cavities and enhance fracture repair [19]. Since autologous bone grafting is associated with the limitations of increased blood loss, surgical time, and risk of donor site infection, it can be used in combination with PRP to circumvent these limitations by reducing the extent of donor bone removal [20]. Moreover, the addition of PRP technology greatly shortens the healing time of bone nonunion, and therefore, the risk of loosening of the internal plate fixation is naturally avoided and the removal of internal plate fixation can be performed sooner [21]. In recent years, PRP technology has undergone widespread research for orthopedic surgical applications. Seijas et al. [22] reported treating delayed clavicle union with plasma rich in growth factors, and the patient regained normal function without pain. In the present report, PRP, autologous bone grafting, and internal plate fixation were used together to treat refractory clavicular nonunion, and the patient regained normal life and function.
This study is not without limitations. The method used includes PRP technique, autologous bone grafting technique, and internal plate fixation technique, making it more complex and technically demanding to perform than other possible methods.
Conclusion
The patient treated with this method had short operative times and good clinical outcomes. We recommend the use of this technique for nonunion of clavicle and even for nonunion of other long-bone fractures.
Footnotes
Conflict of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding
This work was supported by a grant from the Jilin Province Health Science and Technology Capability Enhancement Project (No. 2022LC096).