Yang et al. BMC Musculoskeletal Disorders (2021) 22:294 https://doi.org/10.1186/s12891-021-04148-1 RESEARCH ARTICLE Open Access Complications of clavicle fracture surgery in patients with concomitant chest wall injury: a retrospective study Tsung-Han Yang1,2†, Huan-Jang Ko3†, Alban Don Wang4, Wo-Jan Tseng1,5, Wei-Tso Chia1, Men-Kan Chen6* and Ying-Hao Su1,7,8* Abstract Background: The impact of associated chest wall injuries (CWI) on the complications of clavicle fracture repair is unclear to date. This study aimed to investigate the complications after surgical clavicle fracture fixation in patients with and without different degrees of associated CWI. Methods: A retrospective review over a four-year period of patients who underwent clavicle fracture repair was conducted. A CWI and no-CWI group were distinguished, and the CWI group was subdivided into the minor-CWI (three or fewer rib fractures without flail chest) and complex-CWI (flail chest, four or more rib fractures) subgroup. Demographic data, classification of the clavicle fracture, number of rib fractures, and associated injuries were recorded. Overall complications included surgery-related complications and unplanned hospital readmissions. Univariate analysis and stepwise backward multivariate logistic regression were used to identify potential risk factors for complications. Results: A total of 314 patients undergoing 316 clavicle fracture operations were studied; 28.7% of patients (90/314) occurred with associated CWI. Patients with associated CWI showed a significantly higher age, body mass index, and number of rib fractures. The overall and surgical-related complication rate were similar between groups. Unplanned 30-day hospital readmission rates were significantly higher in the complex-CWI group (p = 0.02). Complex CWI and number of rib fractures were both independent factor for 30-day unplanned hospital readmission (OR 1.59, 95% CI: 1.00–2.54 and OR 1.33, 95% CI: 1.06–1.68, respectively). Conclusion: CWI did not affect surgery-related complications after clavicle fracture repair. However, complex-CWI may increase 30-day unplanned hospital readmission rates. Keywords: Clavicle injuries, Clavicle surgery, Hospital readmission, Postoperative complication, Rib fractures, Thoracic injuries * Correspondence: [email protected]; [email protected] †Tsung-Han Yang and Huan-Jang Ko contributed equally to this work and are both considered as first authors 6Department of Family Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City 30059, Taiwan 1Department of Orthopedics, National Taiwan University Hospital Hsin-Chu Branch, 25, Lane 442, Sec 1, Jingguo Rd, Hsinchu City 30059, Taiwan Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Yang et al. BMC Musculoskeletal Disorders (2021) 22:294 Page 2 of 8 Background were < 18 years old, and 19 patients were lost to follow- Clavicle fractures have traditionally been managed with up before 1 year post-operatively. This led to a study conservative treatment but in recent years surgical fix- population of 314 patients with 316 clavicle fracture ation has become increasingly popular [1–3]. Several fixations. studies have reported an improved fracture union rate Patients with an associated CWI had consultation by with surgical treatment of displaced midshaft and distal either a thoracic or trauma surgeon. Minimal hemotho- clavicle fractures [4–9] compared to conservative treat- races were typically treated conservatively with close ob- ment. The benefits of clavicle fracture surgical treatment servation both pre- and post-operatively. For patients must be balanced with the known risk of postoperative requiring tube thoracostomy, this procedure was typic- surgical complications [10]. ally performed in the emergency department at the time While many clavicle fractures present as an isolated of presentation. injury, a subset of patients also sustain associated injur- ies. Chest wall injury (CWI) is a commonly associated Surgical technique injury in patients sustaining a clavicle fracture with an Twelve board-certified orthopedic surgeons in the incidence ranging from 20 to 60%, and even higher inci- Department of Orthopedics of our institute performed dences have been reported in patients with open clavicle the procedures. Fractures of the clavicle were classified fractures [11–13]. There is a wide range in the severity according to the Arbeitsgemeinschaft für Osteosynthese- of associated CWI. Concurrent rib fractures may nega- fragen (AO) Classification [20]. Displaced AO type 15.2 tively affect the stability of a fractured clavicle. Stahl et al. fracture were treated with either open reduction internal [14] described that concomitant ipsilateral rib fractures fixation (ORIF) with plating or intramedullary fixation significantly increased the rate of displacement of unstable with a Knowles pin. Displaced AO type 15.3 fractures midshaft clavicle fractures. In severe forms of CWI, de- were treated with ORIF using hook plates, distal clavicle layed and retained hemothorax or empyema may develop locking plates, coracoclavicular stabilization, or trans- and impact clavicle fracture management [15–17]. acromioclavicular fixation with a tension band wire. To date, the impact of associated CWI on the post- All patients were treated with a standard post- operative complications in patients undergoing clavicle operative protocol that included initiation of passive mo- fracture fixation has not been thoroughly investigated. tion exercises immediately post-operatively and a sling We hypothesized that CWI increases the complication for 4 to 6 weeks after the surgery. Patients visited the rates in patients undergoing surgical clavicle fracture orthopedic outpatient clinic for monthly follow-ups with treatment. The purpose of this study was to compare the radiographs during the first 3 months post-operatively. complication rates after surgical fixation of clavicle frac- Patients were typically followed for 1 year post- tures between patients with and without CWI. operatively with the timing of subsequent radiographs based on individual surgeon’s preference. Methods Study design Study procedures and variables We performed a retrospective study using ICD-9 code The demographics, body mass index (BMI), current and 810 and ICD-10 code S42.0 to identify patients with former smoking, presence of diabetes mellitus, laterality fractures of the clavicle treated at our institution. of rib fractures, number of rib fractures, AO classifica- tion of the fractured clavicles, and associated injuries Study population were abstracted from the medical record. The presence Patients aged 18 years and older who were diagnosed of an associated injury except for chest wall injuries was with an acute displaced clavicle fracture and underwent defined as a concurrent injury with an Abbreviated In- surgical fixation during a 4-year period between jury Scale ≧3[21]. November 2014 to October 2018 were eligible for this The initial chest radiograph and/or CT scan of the study. Three hundred sixty-nine clavicle fractures under- chest were reviewed, and diagnoses of rib fractures and going surgical treatment and meeting the eligibility associated thoracic injuries were confirmed by a thoracic criteria were identified. The surgical indication of all and a trauma surgeon. The postoperative radiographs of orthopedic surgeons at our institute was similar to that the clavicle were reviewed blindly by two board-certified previously described [9, 18, 19]. Exclusion criteria were orthopedic surgeons (W.T.T. and Y.H.S.). Any objective patient age < 18 years, revision fixation, and pathological radiographic complications, including fracture malunion, fractures. Patients who were lost to follow-up before 1 nonunion, implant loosening, implant breakage, implant year post-operatively or before bone union occurred malposition, and osteolysis, were recorded. Malunion were also excluded. Based on these criteria, we excluded was defined as shortening > 2 cm, angulation > 30 de- 53 patients: 19 patients underwent revision surgery, 15 gree, and translation > 1 cm [22]. Nonunion was defined Yang et al. BMC Musculoskeletal Disorders (2021) 22:294 Page 3 of 8 as no bridging callus by 6 months post-injury. Loosening (interquartile range) for numerical variables and the was defined as presence of halo sign around implants or number (percentage) for categorical variables. The migration of implant