REVIEW ARTICLE

Hook Plate Fixation for Acute Unstable Distal Clavicle

Fracture: A Systematic Review and Meta-analysis
Saeed Asadollahi, MD, FRACS* and Andrew Bucknill, MBBS, Msc, FRCS, FRACS*,†

plate fixation. However, it has a superior functional result compared with

Objectives: To compare the outcome of hook plate fixation with TBW. The complication rate is higher compared with CC stabilization
other techniques in surgical fixation of acute unstable distal clavicle and locking plate fixation and is lower compared with TBW.
fractures.
Key Words: clavicle, hook plate, systematic review, meta-analysis
Data Sources: In July 2018, a systematic search of electronic
databases (PubMed, Medline, Embase, and Cochrane databases for Level of Evidence: Therapeutic Level III. See Instructions for
systematic reviews) was performed according to the Preferred Authors for a complete description of levels of evidence.
Reporting Items for Systematic Reviews and Meta-Analyses guide- (J Orthop Trauma 2019;33:417–422)
line. Articles were limited to English language.
Study Selection: Studies were included if they compared the INTRODUCTION
results of hook plate fixation of acute unstable distal clavicle fracture Distal clavicle fractures account for 10%–30% of all clavicle
in adults with other surgical techniques. fractures.1 Nonoperative treatment of unstable distal clavicle frac-
Data Extraction: Data on the study setting, functional outcome, tures is associated with a high rate of nonunion,2–4 and therefore,
union, and complication rates were extracted. A quality assessment surgical fixation is recommended as the treatment of choice.
was performed using the Newcastle–Ottawa Scale. Several techniques have been described for the opera-
tive fixation of distal clavicle fractures. They include the hook
Data Synthesis: Eleven studies were found that met the inclusion plate,5 locking plate,6 coracoclavicular (CC) fixation,7 tension
criteria. Six hundred thirty-four patients were pooled using a random band wiring (TBW),8 Kirschner wire and Knowles pins,9–11
effects model. There were 397 male and 237 female patients. endobutton,12 and modified Weaver-Dunn.13 Each technique
Primary outcome measure was functional result, and the secondary has its advantages and disadvantages.14 None of the fixation
outcome measures were union and complication rates. There was no techniques is established as the “gold standard.”15
significant difference between the functional outcome and union rate Hook plate fixation is a widely used technique for the
between hook plate fixation, coracoclavicular (CC) stabilization, and fixation of unstable distal clavicle fracture.5,16 Multiple stud-
locking plate fixation. Hook plate fixation resulted in a higher ies have reported the outcome of hook plate fixation17–22;
Constant–Murley score compared with tension band wiring (TBW) however, there have only been a few studies comparing the
[odds ratio (OR), 3.52; 95% confidence interval (CI), 0.79–6.26]. It result of hook plate fixation with other techniques.10,16,23–29
was also associated with a higher complication rate compared with To date, neither qualitative nor quantitative analysis has been
CC stabilization (OR, 3.68; 95% CI, 1.19–11.33) and the locking performed on these studies.
plate (OR, 5.19; 95% CI, 1.58–17.06). Compared with TBW, hook Although randomized controlled trials provide the
plate fixation was associated with a lower complication rate (OR, highest quality of evidence, such studies are limited in
0.28; 95% CI, 0.10–0.77). surgical literature because designing and conducting surgical
trials can be challenging or sometimes logistically impossible
Conclusions: Hook plate fixation achieves a similar functional due to the rarity of the case.30
outcome and union rate compared with CC stabilization and locking
The objective of this study was to analyze and compare
the functional outcome, union rate, and complications
Accepted for publication March 1, 2019. associated with hook plate fixation versus other techniques.
From the *Department of Orthopaedic Surgery, The Royal Melbourne Hospi- The hypothesis of this study was that CC stabilization of
tal, Parkville, Victoria, Australia; and †Department of Surgery (RMH), The
University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria,
acute unstable distal clavicle fracture results in a higher
Australia. functional outcome and lower complication rate compared
The authors report no conflict of interest. with other available techniques.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jorthotrauma.
com).
Reprints: Saeed Asadollahi, MD, FRACS, Department of Orthopaedic METHODOLOGY
Surgery, The Royal Melbourne Hospital, Parkville, Victoria 3050, This systematic review and meta-analysis were conducted
Australia (e-mail: saeedasadollahi@yahoo.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
according to the guidelines set by the Preferred Reporting Items
DOI: 10.1097/BOT.0000000000001481 for Systematic Reviews and Meta-Analyses.31

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Asadollahi and Bucknill J Orthop Trauma  Volume 33, Number 8, August 2019

FIGURE 1. Flow chart of the selection

of papers.

Search Data Extraction/Outcome of Interest

In July 2018, a search of electronic databases including Data were extracted by one author (S.A.). A database
Medline (1946 to July 2018), Embase (1974 to present), was created including the information on the study design,
PubMed, and the Cochrane Library was performed. We used patients’ demographics, type of distal clavicle fixation, follow-
a combination of Medical Subject Headings: “clavicle,” “frac- up, functional outcome, union, and complication rates. Symp-
ture fixation,” “fracture,” “bone,” “adult” and also text words tomatic hardware removal was not recorded and analyzed as
for “lateral clavicle fracture,” “internal fixation,” “distal clav- a complication in this review. The second author (A.B.)
icle fracture,” “hook plate,” “locking plate,” “acute,” and checked the accuracy and completeness of the primary data.
“coracoclavicular” that appeared in the abstracts and titles.
The reference sections of all articles accessed were screened Quality Assessment
for any undetected studies, and an English language restric- Study quality was evaluated using the Newcastle–
tion was applied. Ottawa Scale (NOS).32 The NOS is a simple quality assess-
ment tool for the appraisal of case–control and cohort stud-
Study Selection ies.32 In NOS, study quality is assessed based on 3 items: (1)
Studies were shortlisted if they were related to the selection of study groups, (2) comparability of study groups,
surgical fixation of acute unstable lateral clavicle fracture in and (3) exposure. Stars are given for each category and serve
adults. The abstracts of the shortlisted studies were reviewed, as a visual analogue assessment, with 9 stars indicating the
and selected abstracts were considered for full-text review. highest quality. Also, NOS has been recommended by the
We included all studies that compared hook plate fixation Cochrane Collaboration for quality assessment.33
with other techniques in the surgical treatment of acute
unstable distal clavicle fracture. Case series, case reports, Statistical Analysis
and studies dealing with midshaft or medial clavicle fracture The data from each study was extracted and analyzed
were excluded. using Review Manager 5.3 (The Cochrane Collaboration,

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J Orthop Trauma  Volume 33, Number 8, August 2019 Distal Clavicle Fracture Hook Plate Fixation

TABLE 1. Description of Included Studies

Year Study Fracture Type Number Comparison Groups Male/Female Right/Left Mean Follow-up (mo)
2018 Hsu et al23 Neer II and V 72 Hook plate vs. CC loop technique 45/27 Incomplete data 14
2017 Erdle et al14 Neer IIB 32 Hook plate vs. locking plate 4/28 15/17 54
2017 Yan et al25 Neer II 42 Hook plate vs. CC reconstruction 29/13 10/32 26
2015 Flinkkilä et al16 Neer II 40 Hook plate vs. TightRope 33/7 10/30 46
2014 Chen et al27 Neer IIB 68 Hook plate vs. CC suture fixation 44/24 Not reported 38
2014 Zhang et al34 Neer II 66 Hook plate vs. locking plate 37/29 39/27 28
2012 Tan et al26 Neer II 42 Hook plate vs. locking plate 28/14 27/15 22
2011 Wu et al28 Neer II 116 Hook plate vs. TBW 72/44 Not reported 28
2010 Hsu et al24 Neer II 65 Hook plate vs. TBW 46/19 43/22 6
2009 Lee et al10 Neer II 52 Hook plate vs. TBW 27/25 Not reported 26
2002 Flinkkilä et al29 Neer II 39 Hook plate vs. TBW 32/7 Not reported 52

Copenhagen, Denmark). The random effects model was used operation,16,25–27 length of lateral fragment,14 fragment count,14
for data pooling. For dichotomous variables, the odds ratio CC distance deviation,14 and follow-up period.10,14,16,23,26,27,34
(OR) and 95% confidence intervals (CIs) were calculated. For the purpose of meta-analysis, we divided the
Where the 95 percent CI included 1, the result is considered studies into 3 main surgical technique groups: (1) hook plate
not statistically significant. For continuous variables, the fixation, (2) CC stabilization, and (3) TBW group. The
weighted mean difference (WMD) and 95% CIs were Constant–Murley score was used for the analysis of the
calculated. Any WMD interval that included zero was functional result, as it was the most commonly used outcome
considered not statistically significant. assessment tool among the studies. The study by Hsu et al24
was not included in the functional outcome analysis due to its
short-term follow-up (6 months). In this study, the hook plate
RESULTS was not removed at the time of assessment, which potentially
A total of 714 articles were identified in the initial search underestimates the shoulder function score.26
(Fig. 1). After removing the duplicate records, 698 records Fig. 2 shows the functional outcome following hook
were screened, 674 of which were excluded. The full texts of plate fixation compared with other techniques. There was
the remaining 24 articles were reviewed. Eleven studies met no significant difference in the functional result following
the inclusion criteria. Table 1 outlines the characteristics of the hook plate fixation compared with CC stabilization and lock-
included studies. The total number of patients was 634. Of ing plate. However, hook plate fixation was associated with
these, 397 were male and 237 were female patients. Nine a higher Constant–Murley score compared with TBW (mean
studies were retrospective comparative studies,10,14,16,23,26– difference, 3.52; 95% CI, 0.79–6.26).
29,34 and 2 were prospective randomized trials.24,25 There was no significant difference in the union rate for
The results of the quality assessment performed on the the post hook plate fixation compared with other techniques
studies are shown in Table 2. In all studies, the 2 groups were (Fig. 3). However, the complication rate associated with hook
matched at least for age and sex. Some studies also matched the plate fixation was significantly higher compared with that
groups for fracture side,16,23–26,34 associated comorbid- associated with CC stabilization (OR, 3.68; 95% CI, 1.19–
ities,10,23,24 trauma mechanisms,10,27,28 time from injury to 11.33) and locking plate (OR, 5.19; 95% CI, 1.58–17.06)

TABLE 2. Quality Assessment of Included Studies

NOS Rating
Year Study Level of Evidence Selection Comparability Exposure
2018 Hsu et al23 III ✯✯✯✯ ✯✯ ✯✯✯
2017 Erdle et al14 III ✯✯✯✯ ✯✯ ✯✯✯
2017 Yan et al25 II ✯✯✯✯ ✯✯ ✯✯✯
2015 Flinkkilä et al16 III ✯✯✯✯ ✯ ✯✯✯
2014 Chen et al27 III ✯✯✯✯ ✯✯ ✯✯✯
2014 Zhang et al34 III ✯✯✯✯ ✯ ✯✯✯
2012 Tan et al26 III ✯✯✯ ✯ ✯✯✯
2011 Wu et al28 III ✯✯✯✯ ✯ ✯✯✯
2010 Hsu et al24 II ✯✯✯✯ ✯✯ ✯✯
2009 Lee et al10 III ✯✯✯✯ ✯✯ ✯✯✯
2002 Flinkkilä et al29 III ✯✯✯ ✯ ✯✯✯

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Asadollahi and Bucknill J Orthop Trauma  Volume 33, Number 8, August 2019

FIGURE 2. Forest plot of functional outcome analysis of hook plate compared with (A) CC stabilisation, (B) Locking plate, and (C)
TBW fixation.

(see Figure, Supplemental Digital Content 1, http://links. plate, potential advantages of CC stabilization are avoiding
lww.com/JOT/A686). Hook plate fixation was associated the need for implant removal and other potential complica-
with significantly lower complications compared with TBW tions, such as rotator cuff impingement and acromial frac-
(OR, 0.28; 95% CI, 0.1–0.77). ture.37 The result of the current meta-analysis confirms this
with the odds of complication being 3.68 times less after CC
DISCUSSION stabilization compared with those after hook plate fixation.
Hook plate fixation is a reliable technique for distal Locking plates rely on multiple screw fixations in the
clavicle fracture surgical treatment.21 The subacromial hook distal fragment to restore CC stability.17 The anatomical
provides distal leverage that allows the reduction of the supe- design and low-profile plate reduces the potential need for
riorly displaced medial fragment. Our findings are in line with plate removal.38 Although the complication rate associated
previous reports showing that hook plate fixation achieves with locking plate fixation is lower than that associated with
a comparable functional outcome and high union rate similar hook plate, locking plate alone may not be suitable for a very
to other techniques.15,35 However, the hook contact can pre- distal fracture, comminuted fracture, or osteoporotic bone,
dispose to subacromial space inflammation, rotator cuff where the distal fragment cannot hold screws. Under these
impingement, acromion osteolysis and fracture.15,22,25,36,37 circumstances, plate fixation combined with CC stabilization
Subacromial position of hook of the hook plate and its can be used to reduce fixation failure.38
leverage force predisposes specific subset of complications Tension band wire fixation using transarticular or extra-
manifesting as shoulder pain and limited range of move- articular K-wire is one of the earliest described techniques for
ment.15,22,25,36,37 The most common complications following the fixation of unstable distal clavicle fracture.10 Our findings
hook plate fixation in this review (n = 59) were subacromial show that TBW can achieve a functional outcome similar to
osteolysis or erosion (27%), acromioclavicular arthrosis (22%), hook plate fixation. The 3.52 WMD in the Constant–Murley
and peri-implant fracture (22%). How to improve the design of score between the TBW and hook plate fixation, although
the hook plate or finding the ideal time to remove it before statistically significant, is less than the minimum clinically
complication occurs can be the focus of future studies. important difference of 10.4 to show any clinical signifi-
Various methods of CC stabilization have been cance.39 However, the present meta-analysis shows that the
described in the literature.16,23,25,27 Compared with hook odds of complication occurring with TBW are 3.2 times higher

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J Orthop Trauma  Volume 33, Number 8, August 2019 Distal Clavicle Fracture Hook Plate Fixation

FIGURE 3. Forest plot of union rate following hook plate fixation compared with (A) CC stabilisation, (B) Locking plate, and (C)
TBW fixation.

compared with those occurring with hook plate fixation. This is associated with hook plate fixation is higher compared with
in line with previous reports that found the complication rate that associated with CC stabilization and locking plate and
associated with TBW to be unacceptably high.10,28,40 lower compared with that associated with the TBW technique.
The meta-analysis of observational studies combines
results that are clinically and methodologically diverse.41 Our
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