Surgical Treatment of Post-Radiotherapy Nonunions of the...
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125 Bulletin • Hospital for Joint Diseases Volume 62, Numbers 3 & 4 2005 Abstract Fractures of irradiated bones present special challenges to healing. Nonunions are very common and are challenging surgical problems. We report three radiated nonunions of the clavicle successfully treated with modifications of standard internal fixation techniques. R adiation therapy is commonly used in the treat- ment of numerous malignant tumors. Therapeutic doses of radiation can lead to weakened, devas- cularized, and fractured bones. 1 Doses of radiation less than 3,000 rads do not prevent healing of pathologic fractures of long bones, especially when combined with open reduction and internal fixation (ORIF). However, pathologic fractures subsequent to radiation dosages exceeding 3,000 rads without the benefit of ORIF do not unite. 2 The clavicle is commonly included in the radiation treatment field for cancers of the neck, breast, and fore- quarter regional lymph nodes. Furthermore, the clavicle is one of the most frequently fractured bones, although nonunion is uncommon. Clavicle fractures occurring in high-dose radiation fields will not unite. A review of the literature did not reveal any contributions addressing treatment of radiated nonunions of the clavicle. We pres- ent successful surgical treatment of three patients who underwent high-dose radiation treatment for cancer and subsequently suffered pathologic fracture and nonunion of the clavicle in the radiation field. Case Histories During September 1999 three patients presented to the musculoskeletal tumor service with painful nonunions of the clavicle. All three patients had undergone radio- therapy for neoplasms in the past. The radiation fields in all cases included the area of fracture, and radiation was delivered with curative intent at near-maximal doses. All patients had secondary radiation changes, and two also had previous surgical removal of soft tissues at or adjacent to the clavicle. Patient A is a 61-year-old male who 10 years pre- viously underwent a laryngectomy, left radical neck dissection, and tracheostomy for invasive squamous cell carcinoma of the larynx. He was then treated with “maximum dose” radiation to the neck and adjacent lymph nodes and soft tissues, and is free of disease. The left clavicle, sternum, and ribs were fractured in a motor vehicle accident (MVA) in January 1999. The sternum and ribs healed, but the clavicle went on to a painful nonunion. Patient B is a 70-year-old osteoporotic female who, in 1967, underwent radical mastectomy for breast cancer. She then underwent a 30-day cobalt radiation treatment to the left chest wall and axilla including the region of the left clavicle. She has been free of disease since that time, although her arm function was significantly compromised by post-radiation lymphedema. Onset of clavicle pain in June 1999 prompted an X-ray that was negative for fracture. Subsequently, a fracture line developed and showed no radiographic or clinical heal- ing over four months. The patient wanted surgery, but refused autogenous bone graft. She also refused the use of growth factor-laden material due to concerns about Surgical Treatment of Post-Radiotherapy Nonunions of the Clavicle Glenn Wera, M.D., David Glenn Mohler, M.D., and Loretta Chou, M.D. Glenn Wera, M.D., is in the Department of Orthopaedics at Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio. David Glenn Mohler, M.D., is an Assistant Clinical Professor in the Department of Orthopaedic Surgery and Sports Medicine, Stanford University Medical Center, Stanford, California. Loretta Chou, M.D., is an Assistant Professor in the Department of Orthopaedic Surgery and Sports Medicine, Stanford University Medical Center, Stanford, California. Correspondence: Glenn Wera, M.D., Department of Orthopaedics 11100 Euclid Avenue, Cleveland, Ohio 44106.
Transcript of Surgical Treatment of Post-Radiotherapy Nonunions of the...
125 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005
Abstract
Fractures of irradiated bones present special challenges to healing. Nonunions are very common and are challenging surgical problems. We report three radiated nonunions of the clavicle successfully treated with modifications of standard internal fixation techniques.
Radiationtherapyiscommonlyusedinthetreat-mentofnumerousmalignanttumors.Therapeuticdosesofradiationcanleadtoweakened,devas-
cularized,andfracturedbones.1Dosesofradiationlessthan 3,000 rads do not prevent healing of pathologicfracturesoflongbones,especiallywhencombinedwithopenreductionandinternalfixation(ORIF).However,pathologic fractures subsequent to radiation dosagesexceeding3,000radswithoutthebenefitofORIFdonotunite.2Theclavicleiscommonlyincludedintheradiationtreatmentfieldforcancersoftheneck,breast,andfore-quarterregionallymphnodes.Furthermore,theclavicleisoneofthemostfrequentlyfracturedbones,althoughnonunionisuncommon.Claviclefracturesoccurringinhigh-doseradiationfieldswillnotunite.Areviewoftheliterature did not reveal any contributions addressingtreatmentofradiatednonunionsoftheclavicle.Wepres-entsuccessfulsurgicaltreatmentofthreepatientswhounderwenthigh-doseradiationtreatmentforcancerand
subsequentlysufferedpathologicfractureandnonunionoftheclavicleintheradiationfield.
Case HistoriesDuringSeptember1999threepatientspresentedtothemusculoskeletal tumor servicewithpainfulnonunionsoftheclavicle.Allthreepatientshadundergoneradio-therapyforneoplasmsinthepast.Theradiationfieldsinallcasesincludedtheareaoffracture,andradiationwasdeliveredwithcurativeintentatnear-maximaldoses.Allpatientshadsecondaryradiationchanges,and twoalsohadprevioussurgicalremovalofsofttissuesatoradjacenttotheclavicle. PatientA is a 61-year-old male who 10 years pre-viously underwent a laryngectomy, left radical neckdissection, and tracheostomy for invasive squamouscellcarcinomaofthelarynx.Hewasthentreatedwith“maximum dose” radiation to the neck and adjacentlymphnodesandsofttissues,andisfreeofdisease.Theleftclavicle,sternum,andribswerefracturedinamotorvehicleaccident(MVA)inJanuary1999.Thesternumand ribs healed, but the clavicle went on to a painfulnonunion. PatientBisa70-year-oldosteoporoticfemalewho,in1967,underwentradicalmastectomyforbreastcancer.Shethenunderwenta30-daycobaltradiationtreatmentto the left chest wall and axilla including the regionof the leftclavicle.Shehasbeenfreeofdiseasesincethat time,althoughherarm functionwas significantlycompromised by post-radiation lymphedema. Onsetof clavicle pain in June 1999 prompted an X-ray thatwasnegativeforfracture.Subsequently,afracturelinedevelopedandshowednoradiographicorclinicalheal-ingover fourmonths.Thepatientwantedsurgery,butrefusedautogenousbonegraft.Shealsorefusedtheuseofgrowth factor-ladenmaterialdue toconcernsabout
Surgical Treatment of Post-Radiotherapy Nonunions of the Clavicle
Glenn Wera, M.D., David Glenn Mohler, M.D., and Loretta Chou, M.D.
GlennWera,M.D.,isintheDepartmentofOrthopaedicsatCaseWesternReserveUniversity,UniversityHospitalsofCleveland,Cleveland, Ohio. David Glenn Mohler, M.D., is anAssistantClinicalProfessorintheDepartmentofOrthopaedicSurgeryandSportsMedicine,StanfordUniversityMedicalCenter,Stanford,California.LorettaChou,M.D.,isanAssistantProfessorintheDepartmentofOrthopaedicSurgeryandSportsMedicine,StanfordUniversityMedicalCenter,Stanford,California.Correspondence:GlennWera,M.D.,DepartmentofOrthopaedics11100EuclidAvenue,Cleveland,Ohio44106.
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potentialcarcinogeniceffects. Patient C is a 61-year-old male who underwentchemotherapy and high-dose radiation treatment fornon-Hodgkins lymphoma (NHL) in the region of theclavicleduring1982.Hefracturedtheleftclaviclenineyearspriortosurgeryanddevelopedapainfulnonunion.Multiplesurgeonshadrefusedoperationduetothepoortissue quality and the patient’s insistence on avoidingautogenousbonegraft.
Materials and MethodsAllpatientsunderwentopenreductioninternalfixationwithdifferent techniquesappropriate to theirclinical situationand respecting their individual treatment constraints.Allpatientswereoperateduponbytheseniorauthor(DGM).Titaniumwasusedexclusivelytomaximizetheutilityofanyfuturemagneticresonanceimaging.Topreventvascu-lar injuryandallow thehardware to remainpermanentlyfixed, blunt tipped, non-self-tapping/self-drilling screwswereusedandallscrewtipswerekeptatbutnotthroughthecortex.Perioperative intravenousantibiotics followedbyoralantibioticswereusedfor72hoursinallcases.Skinsutureswere left for threeweeks.Slingswereusedfor6weeks,exceptfordailyshowers.Pendulumexerciseswerebegunatdaytwoandpassivemotionunderphysicaltherapyguidancewasinstitutedbetweenweeks3and4followingradiographsnegativeforlossofreduction.Activerangeofmotionwasinstitutedat6weeksinallcasesfollowingasecondradiographconfirmingsolidfixation. Twopatientswereevaluatedat9and28monthsaftersurgery (patients B and C). PatientA was evaluated 9monthspostoperativelybutdiedbeforethe2-yearfollow-up.Radiographsweretakenintheanterior-posteriorplaneandat20°cephaladviewinordertoassessevidenceoffixationfailureandnonunion.Outcometestingwasperformedus-ing the Constant-Murley3 shoulder score and the SimpleShoulderTest.4WechosetheConstant-Murleymethodtoassessshoulderfunctionbecauseitthoroughlyaccountedforpain,lifestyle,rangeofmotion,andpowerusingphysicalexaminationandquestioning.Moreover,itwaseasytouseintheclinicalsettingandhasbeenshowntoproducelowintraobserverandinterobserverscoredifferencesbyConboyandcolleagues.5TheSimpleShoulderTestwasalsousedtoevaluatethestatusofthesepatientspostoperativelybecauseitwasfoundtoproducesimilarresultscomparedtootherpopularshoulderratingsystems.6TheSimpleShoulderTestsystemisa12-itemquestionnairethatalsoaccountsforpain,rangeofmotion,dailyactivity,andpower.Bothshoulderassessments give a numerical percentage score with onehundredrepresentingnormalandfullfunction.
Operative Techniques Patient AThis patient had radiation effects consisting of thin,desquamatingpigmentedskin,andatracheostomyim-
mediatelyadjacent to theoperativearea.Aftercarefuldrapingandpreparationoftheoperativesite,anincisionwasmade inferiorandparallel to the left clavicleandcarrieddeeptotheplatysmamuscle.Afullthicknessflapwasthendevelopedsuperiorly,exposingthenonunionoftheclavicle.Thepseudoarthrosiswastakendownwithrongeurs.Aburrwasusedtocutaslotintotheanteriorcortexofthetwoboneendsfortheplacementofaninlaybonegraft.Reductionwas thencarriedout. Iliaccrestbonegraftwasharvestedandconvertedtomatchsticksandcancellousslurry.Thebonegraftwasplacedintheslot,traversingthenonunionsite.Aninter-fragmentaryscrewwasplacedinalagfashiontoholdthereductionandcompresstheboneends.Aten-hole3.5mmtitaniumdynamiccompressionplatewascutdowntonineholes,contoured,andfixedwithscrews.Screwtipsweremanu-allycheckedforprotrusionfromtheinferiorclavicularsurface.Theremainingautogenousbonegraftwasplacedaround the nonunion site. Grafton® (Osteotech, Inc.,Eatontown,NJ)demineralizedbonematrix(DBM)wasadded around the site of nonunion. Soft tissues wereclosed in multiple layers followed by small, closelyplacedskinstapleswithperfectdermalalignment.An-tibioticointmentwasappliedtothestaplelinepriortocoveringwithanocclusivesteriledressing.
Patient BThispatientwasverythin,osteoporotic,andhadarela-tivelyshortmedialclaviclesegmentallowingnomorethatthreescrewsforfixationinthemedialfragment.Inaddition,shedidnotwanttheplateremoved,aprocedurecommonly performed to avoid late subclavian arterydisruptionfrompulsationagainstprominentscrewtips.Shehadpreviouslyhadallmuscletissueremovedfromthe clavicle as part of her radical mastectomy.To ac-complishfixationwiththeseconstraints,ananteriorplateplacementwasplanned,withsupplementalmethylmeth-acrylatetoreinforcetheshortmedialclaviclesegment.Aninferiorincisionwasmadeandafullthicknessflapwasraised.Thenonunionsitewasrongeuredtoremoveallthefibroustissue.Thecanalofthemedialportionofthe clavicle was reamed using a curette to remove allfibroustissue.Bonecementwasmixedwithmethyleneblue.Thecementwasinjectedintothemedialclavicleto provide additional purchase for screw fixation intheshort,extremelyosteoporoticbone.A9-holeplatewascontouredtomatchtheanteromedialaspectoftheclavicleandcurvedaroundthelateralanterior-superioraspect.Themedialscrewswereplacedfirst.Carewastakentoavoidprominentscrewtipsatthefarcortexofthebone,whichcouldpotentiallyerodeintovesselsorthepleura.Afterplacementofthethreemedialscrews,thefracturewasreduced.Gapsinthenonunionsitewerefilledwithallograftcancellousbonechipspriortoplace-mentofthelateralfragmentscrewsincompression.Ad-
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ditionalallograftwaspackedaroundthenonunionsite.DBMwasnotusedduetothepatient’sconcernabouttheimpactofgrowthfactorsonpossibletumorgenesis.Thewoundwasclosedinthreelayers.Woundclosurestripswereplacedoverthewoundfollowedbynitropastewiththeintentionofenhancingskinperfusionandpreventingwoundedgenecrosisinthiscompromisedtissue.
Patient CAn inferior full-thickness flap was developed and thenonunion exposed. Fibrous tissue was removed fromthenonunionsite.Extraboneat thefractureendswasremovedpiece-mealwitharongeurandsetasideforuseasbonegraft.Thefracturewasreducedandalagscrewwasplacedforinitialstabilization.Next,a3.5mm10-holedynamiccompressionplate(DCP)wasappliedandfixedwithscrews.Themorselizedbonefromtheclavicleendswasplacedatthefracturesite.Atthefracturesite5ccofGrafton®puttywasusedtocomplementfracturehealing. The deep layer was closed with 2-0 chromicsutures.Once thiswasdone, theskinwasclosedwith
running3-0Prolenesuture,woundclosurestrips,andasteriledressing.
ResultsAtaminimumof28-monthsfollow-up,patientsBandCwerepainfreewithdailyactivities.However,PatientAstillexpressedsomediscomfortduringsleepat9months.PatientAdiedduetoliverandrenalfailuresecondarytoethanolabuse22.5monthsaftersurgery.Atelephoneinterviewwiththepatient’sspouseindicatedthathisclavicleandshoulderfunction were absolutely unchanged since his 9-monthfollow-up evaluation at our clinic. Radiographs taken at9-monthsfollow-upshowednolossoffixation,platelift-off,orlyticchangesaroundthehardware(Figs.1,2and3).Twoofthreefracturelineshavedisappeared(Figs.1and3),whilethethird(Fig.2)couldnotbeevaluatedbecauseofplateplacementandthecementartifact.At28-monthspostoperatively, patients B and C were re-imaged with
Figure 1RadiographsofPatientA,leftclavicle.Fromtoptobot-tom:preoperative,postoperative,and9-monthfollow-up.Abonyunionisapparentat9months.Notethelackofprotrusionofscrewtipsintheregionofthegreatvessels.
Figure 2RadiographofPatientB,leftclavicle.Fromtoptobot-tom:preoperative,postoperative,and9-monthfollow-up.Fracturelineinthemedialclavicleisseenonthetopradiograph.Bonyunioncannotbeconfirmedduetocementartifact.Noteanteriorplace-mentofplateandscrewstoavoidthegreatvesselsandobviatetheneedforplateremoval.
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plainradiographs.Thesenewimageswereunchangedfrompreviousvisits.Therewerenoinstancesofwoundinfection,woundbreakdown,ordelayedhealing.Allplatesarereadilyvisiblethroughtheskin,buttherewasnoevidenceofskincompromiseoverthehardware.Nopatientwishedtohavetheirhardwareremoved.
Assessmentof shoulder function is shown inTable1.Nopatientshadnormalshoulderfunctionontheleft,frac-turedside.However,allpatientssubjectivelyfelttheyhadreturnedtopre-fracturefunction,andwerepleasedwiththeiroutcome. InPatientA,inferiorsubluxation,pain,andinstabilityhave been eliminated.The bone has united according toradiographicexamination.Hewastheonlypatienttohavesomepainintheshoulderathislastfollow-up.Thispatienthad some mild discomfort at night only.The remainingshoulderdeficit(Table1)oftheaffectedlimbisaresultofradicalneckdissectionwhichincludedremovalofsubstan-tial amounts of muscle including deltoid, trapezius, andsternocleidomastoid. InPatientB,clickingpainwaseliminated.However,poorforwardflexionandabductionpersistedasaconsequenceofpre-existingchroniclymphedema.Theaffectedlimbisheavyandweakdistaltotheshoulderresultinginlowassessmentsofshoulderfunction.HerConstant-Murleyscoredecreasedat28monthscomparedto10monthsduetolossofpowersecondarytolymphedemaanddisuse(Table1). InPatientC,tentingoftheskinwaseliminated.Thepa-tienthasahistoryofbilateralrotatorcuffinjuryaccountingforthereducedshoulderscoresinbothshoulders(Table1).However,therightshoulderexhibitedabetterassessmentduetosuccessfulshoulderarthroscopyperformedonthatsidebeforeORIFoftheclavicle.HisConstant-MurleyScoreandSimpleShoulderTest,whichimprovedat28monthscomparedto10mothsaftersurgery,wereattributedtocondi-tioningthatincludedfrequentgolfandvehiclemaintenance.Remarkably,thepatientwasthrownfromamotorcycleatanestimated40milesperhourapproximately6monthsaftersurgery.Hesufferednomajorinjuriesorre-fractureoftheaffectedclavicle.
DiscussionThedeleterious effects of ionizing radiationonbone arewelldocumentedinbothanimalmodelsandclinicalstud-ies.Inaratmodel,longbonesoftheappendicularskeleton
Figure 3RadiographofPatientC,leftclavicle.Fromtoptobot-tom:preoperative,postoperative,and9-monthfollow-up.Abonyunionispresentat9months.
Table 1 DetailsofThreePatientswithNonunionoftheLeftClavicleSecondarytoRadiationTreatment
Constant-Murley Simple Patient, Duration Shoulder Shoulder Age, Immediate Radiation of Score Test Nonunion FixationGender Cause Treatment Symptoms Nonunion Right:Left Right:Left Healed Failure Complications
A MVA MaxLarynx Inf.Subluxation 8mos. 10mos.:90:66 10mos.:100:83 Yes No None61 1980s Pain M Instability
B Unknown 30days Clickingpain 4mos. 10mos.:95:47 10mos.:100:33 Yes No None70 CABreast Poormotion 28mos.:95:37 28mos.:92:33 F 1967 forwardflexion abduction
C Re-fracture Non-Hodgkins Tentingskin 9years 10mos.:86:88 10mos.:92:67 Yes No None61 Lymphoma Pain 28mos.:93:93 28mos.:100:92 M 1982
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showedincreasedriskoffracturefollowingdosesof5,000radsorgreater.7Biochemicalandhistologicalmarkersofhealingeventuallyrecovertolevelsnodifferentfromcon-trols in irradiated rat femurs.8 Nevertheless, the negativeeffectofradiationonbonehasbeendemonstratedtocauselong-termweaknessanddelayedfracturehealinginrats.9Thispersistentimpairmentofthebonerepairmechanismsisdemonstratedbyourpatients’initialinabilitytohealtheirclaviclefracturesdespitetheintervalofasmuchas22yearsbetweenradiationandfracture(Table1). Inonepatient,fractureoccurredintheabsenceofaknowntraumaticevent.Rat femurshavebeenshown to fracturespontaneouslyafterhigh-doseirradiation.Healedfracturecallous in irradiatedbonewasweakerand lessmatureatallradiationexposurelevels.Thestrengthofthefinalbonyunionremainedlessthanthecontrolforalltheexperimentalsubjects.10Clinicalstudiesshowbonesubjectedtohigh-doseradiationdemonstratesan increasedincidenceofdelayedunionandnonunion,andanincreasedincidenceoffractureandre-fracture.11Arecentreportindicatedthatthesurgicalremovalofperiosteummaydramaticallyincreasefractureriskinradiatedbone.12
Fractures of the clavicle are common and most unitewithouttheneedforsurgery.Inalargegroupof242subjectswithdisplacedmid-shaftclaviclefractures,openreductionandinternalfixationresultedinimprovedoutcomescom-paredtoclosedtreatment.13Whennonunionsoccurandareleftuntreated, soft-tissueproblems,contractures,andde-creasedrangeofmotioncommonlyresult.14Amongclaviclenonunions not involving radiotherapy, decortication withplateosteosynthesisprovedbothtobeareliableandlastingsolution.15The combination of plating and bone graftingofpainfulclaviclenonunionsproducesthehighestratesofunionwithminimalcomplications.16,17Wuandassociates18foundsurgicallytreatedclaviclenonunionstohavelowerratesofsuccessfulunionthannonunionsofotherbones.Thisreducedhealingpropensityisascribedtopoorvascularityandasparsesofttissueenvelope.Inourcases,surgicalre-movalofsurroundingsofttissuesfortumortreatmentandsofttissueinjuryfromradiationexposureexacerbatesthisproblem. Eachofthepatientsinthisstudyunderwentsignificantradiationtherapyforcancerbeforesufferingchronic,per-sistent, nonunion of the clavicle. Gainor and coworkers2reportedonpatientswithlongbonefracturesafterradiationtreatmentofmetastases.Althoughsuchpatientssufferfromweakenedboneandretardedhealingrates,internalfixationimprovedtherateoffractureunionby23%comparedtocast immobilization.All fractures in bones that received3,000radormoredevelopednonunionif treatedwithoutsurgery.Giventhatallourpatientsreceiveddosesofatleastthisamount,nonunionwastheexpectedoutcomefortheirfractures. In approaching these specific patients, the surgicaltechniquewasadjusted toaddress themechanical and
biological problems inherent in the radiated cancersurvivor. First, incisions were placed to avoid tensionareasandtobeatadistancefromtheplateandclavicleprominence. In this fashion,anyskinhealingproblemwouldnotexposethehardwareorbone.Flapswerekeptfullthicknesstomaximizeskinvascularityandpreventedgenecrosis.Titaniumwasselectedinsteadofstainlesssteeltoallowtheuseofmagneticresonanceimagingwithminimalartifact.Becauseoftheweakenedbone,platelengthstoalloweightormorecorticesoffixationoneachsideofthefracturewereselected.Inadditiontheplatesaremeanttobepermanent,asre-fractureafterremovalwouldbelikely,andfurthersurgeryinaradiatedareaistobeavoidedwheneverpossible.Plateplacement,screwlengths,andorientationweredesignedtoavoidproblemswithplateerosionthroughskinandvascularinjuryfrompointed,prominentscrewtips. Inonecase (PatientB)with a medial fracture and osteoporosis, the medialfragmentwasfilledwithmethylmethacrylatecementtoincreasethepull-outstrengthofthescrewsandenhancerigidity.Theboneendsatthenonunionwerefreshenedandcontouredtoallowmaximumintimatecontact,andcompressionwasappliedthroughtheuseoflagscrewsanddynamiccompressionplates.Biologicenhancementofthefracturerepairprocesswasachievedthroughtheuseofiliaccrestbonegraft,allogeneicgrowthfactors,allograft cancellous bone, or combinations of thesewherepossible.Skinandsofttissueclosuresweredonemeticulously, and antibiotics were continued past theperioperativeperiodtopreventbacterialinvasionthroughtheslow-healingskinlayers. The patients’ radiographic results indicate successfulunion.Although fracture linesareno longervisible, it isveryhardtoevaluatepresenceorabsenceoffracturelinesaftergraftingandplating.Thelackofpainandtheabsenceofanyplatelift-offorlysisaroundthescrewsat9and28monthsaftersurgeryisgoodevidencethatthepatientshavehealed. Functionalassessmentthroughtheuseofscoringsystemsisproblematicinthispopulation.Allthreepatientshadfunc-tionaldeficitsindependentoftheirclaviclenonunions.Twohadsubstantialsofttissueresectionsaspartoftheircancertreatmentandthethirdpatienthadbilateralrotatorcuffpa-thology.TheConstant-MurleyscoreandSimpleShoulderTestreflectedthatthepatient’sshoulderswerestable,strong,andmobile.Bothsystemsarebasedonapercentageofnor-malfunction.Althoughtheydidnotresultinequalscores,the comparison of the affected limb to unaffected limbwasconsistentinallthreesubjects.ThelargestdifferencestemmedfromthefactthattheConstant–Murleysystem’sscoreforpowerinvolvedmeasuringtheabilityofapatienttoresistforceduringabductionwhereastheSimpleShoulderTestquestionedthepatient’sabilitytothrowaballinoverandunderhandfashions.Italsoassessedpowerbyques-tioningthepatient’sabilitytocarrythreedifferentweights
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at threedifferentpositions.Otherwise theassessment forrangeofmotion,pain,andphysicalactivityincludingworkand leisure were very consistent.All patients improvedtheir shoulder function postoperatively and approachedtheperformance levelof theirunaffected limb.PatientAhada lastingdeficitofshoulderfunctionduetopreviousradicalneckdissectionforlaryngealcancer,withresectionoftheanteriordeltoid,trapezius,andsternocleidomastoid.Accordingly,rangeofmotionwasdecreased,manifestingin low scores according to both methods of assessment(Table1).NoweaknesscouldbeattributedtotheORIFoftheaffectedclavicle.PatientBhadlastingdeficitoftheaf-fectedlimbduetopersistentlymphedemastemmingfromherradiationtreatmentforbreastcancer.Consequently,theaffectedlimbdemonstratedapoorrangeofmotionthatlow-eredbothshoulderscores.Disuseoftheaffectedlimbleadtolossofpowerandlowerscoresat28monthscomparedtoher10-monthassessment.However,thisdeficitwasnotaconsequenceofORIFoftheaffectedclavicle.PatientChadsomeperformancedeficitoftheaffectedlimbduetobilateral rotator cuff injury.Although he had undergonesuccessfularthroscopyof therightshoulder,weassessedbothshouldersasapproximatelyequalatthe10-monthas-sessment.Thisresultsuggeststhattheaffectedleftshoulderfunctionwascompletelyrestoredoutsideoftherotatorcuffinjury.Thispatienthasanactivelifestylethatincludesbothgolfandautomobilemaintenance.Hisimprovedshoulderscoresat28monthsareattributedtogainsinpowerstem-mingfromlifestyle-relatedconditioning.Thefactthatthispatientsufferedamotorcycleaccidentthatdidnotresultinre-fractureatteststotheviabilityofORIFoftheclavicleinthesepatients.Allpatientsreportedsignificantreliefofpainandimprovedrangeofmotionatlastfollow-up.
ConclusionThisstudydescribesmethodstoachieveexcellentoutcomesin treating radiated clavicle nonunions. Rigid, long platefixationsupplementedwithautogenousiliaccrestbonegraftandcarefulsofttissuemanagementisthepreferredmethodof treatment. Successful outcomes can be achieved withmodificationsofthisideal.
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