Satisfactory results in five patients with septic clavicle nonunion using the modified Masquelet technique and structural iliac crest autograft

Abstract

IntroductionIndications for clavicle fracture fixation have increased dramatically over the last 20 years. Chronic surgical site infection is a particularly severe complication arising from this procedure and can induce nonunion and clinical disability. In such cases, the Modified Masquelet technique using iliac crest autograft (cancellous or tricortical) enables treatment of any bone infection as well as reconstruction of the segmental defect. The aim of this study was to analyze clinical and radiological results of this procedure at mid-term follow-up. MethodsIn this monocentric retrospective study, patients suffering from a septic clavicle nonunion were treated with a Modified Masquelet technique and reviewed at a minimum follow-up point of two years. They were clinically assessed using active range of motion, pain score (Visual Analogic Scale VAS 0 to 10), Constant score, American Shoulder and Elbow Surgeon (ASES) score, and Subjective Shoulder Value score (SSV). Bone healing was measured using standard X-rays and CT scans. ResultsFive patients were included (mean age 49 years; range 30-62). C. acnes was involved in 80% (n=4) of these cases. Following the first stage of treatment, the mean bone defect was 3.4 cm (range 2.6-6.4 cm). The second stage, performed at a minimum of six weeks (mean 7±1 weeks), used an iliac crest bone autograft in all cases. At mean follow-up of 5±3 years, mean pain score was 0.3/10 points (0-1), mean Constant score was 86 points (78-96), mean ASES score was 98±2%, and the SSV score 91±11%, with two “forgotten shoulders” out of five. On CT scan analysis, bone healing was achieved in 100% of cases. One plate (20%) was removed one year following the procedure due to the patient’s discomfort; pain and discomfort at the iliac crest site was reported in 5/5 (100%) patients. ConclusionThe Modified Masquelet technique using iliac crest autograft is a reliable and effective technique for treating septic nonunion of the clavicle. It both treats the bony defect and eradicates infection when conducted in association with débridement and antibiotics. In the five cases reported here, this approach had satisfactory results, both subjectively and objectively, with a very low re-operation rate despite persistent pain from iliac bone harvesting.