Supplementary fixation in multifragmentary midshaft clavicle fractures: do interfragmentary screws or suture cerclage improve outcomes compared with plate-only fixation?

BACKGROUND

Clavicle fractures are common injuries. As displaced or multifragmentary midshaft patterns carry a substantial risk of malunion and nonunion with nonoperative treatment, they have contributed to the increasing use of surgical fixation. Modern operative techniques include plate fixation, intramedullary devices, and hybrid strategies to address comminution and improve fragment stability. Supplementary interfragmentary screws and cerclage constructs have been proposed to enhance fragment control and optimize load transfer in multifragmentary fracture patterns. This study aimed to compare three fixation strategies for operatively treated midshaft clavicle fractures managed with plate osteosynthesis: Group IS (interfragmentary screw), Group CA (cerclage augmentation), and Group POF (plate-only fixation), with respect to operative time, complication rates, and potential biological and mechanical differences.

METHODS

This retrospective study included patients aged ≥ 16 years who underwent plate fixation for multifragmentary clavicle fractures between 2016 and 2024. Patients were categorized into three groups: Group IS (supplementary interfragmentary screw), Group CA (suture cerclage augmentation), and Group POF (plate-only fixation). Demographic, surgical, and radiographic data were collected. Callus formation was assessed by three independent observers. Statistical analyses were performed with a significance level of p < 0.05.

RESULTS

A total of 246 patients (mean age 44.5 ± 15.7 years; 89% male) were included. The overall complication rate was 6.9%. Fracture complexity differed significantly between groups (p = 0.0083), with Group IS and Group CA including more complex fracture patterns. Operative time was longest in Group CA (101.1 min), followed by Group IS (90.1 min) and Group POF (82.4 min; p < 0.001). Group IS and Group CA demonstrated lower complication rates (6.0% and 5.5%, respectively) compared with Group POF (16.3%, p = 0.0444). Mechanical complications were absent in Group CA (p = 0.035). Differences in callus formation were observed between groups (p = 0.0059). Refracture rates after implant removal were highest in Group CA (16.0%), with no refractures observed in Group POF (p = 0.064).

CONCLUSION

While the choice between interfragmentary screws and cerclage is primarily dictated by fracture morphology, our findings suggest that supplementary fixation may be beneficial in multifragmentary fractures. Both strategies were associated with lower complication rates compared with plate-only fixation; however, refracture rates after implant removal may be higher and require cautious interpretation. Further studies are needed to clarify the long-term clinical impact of these strategies.

LEVEL OF EVIDENCE: Level III, Retrospective cohort study.