Abstract
Objectives:
Clavicle fractures are a leading cause of injury among adolescent athletes. While the majority of these injuries may be managed nonoperatively, open reduction internal fixation (ORIF) is sometimes warranted due to fracture or patient-specific factors. Traditional consensus for return to play (RTP) following clavicle ORIF is 12-16 weeks. To date, however, there is a paucity of data on the safety of an accelerated RTP timeline following these procedures, and whether patients may safely RTP before 12 weeks is unclear. Therefore, the purpose of this study was to assess the safety of an accelerated RTP timeline following ORIF of adolescent clavicle fractures.
Methods:
This was a retrospective review of a single dual-fellowship-trained pediatric sports medicine orthopedic surgeon for consecutive adolescent patients (age 12-17 years) undergoing ORIF of a midshaft clavicle fracture from 2016 to 2024 with minimum 6-month follow-up (chosen as a timeframe which allows ample time to sustain early refracture). The senior author surgeon traditionally allowed RTP consistent with historical guidance of ~12-16 weeks postoperatively, before shifting to an accelerated RTP timeline ~6-10 weeks postoperatively at the approximate midpoint of the study period (September 2020). Consecutive patients before and after this shift were reviewed to minimize confounding (there were no other changes in any aspect of surgical technique, indications, or physical therapy protocol between periods). Demographic, injury, and surgical details were collected. Time to RTP was defined as the time from surgery to the time the patient was given full clearance for unrestricted contact sports. The primary outcome was refracture. Additional outcomes included infection, wound complications, and removal of hardware. Results were compared between the accelerated (typically 6-10 weeks) and traditional (typically 12-16 weeks) RTP cohorts with univariate analyses (i.e., Chi-squared and Student t-tests, as appropriate).
Results:
There was a total of 23 patients (0% loss to follow-up), including 12 patients in the accelerated RTP group and 11 patients in the traditional RTP group. There were no differences in sex (83.3% vs. 90.9% male, p>0.99), age (mean 14.8 years vs. 15.3 years, p=0.47), displacement (mean 1.3 shaft widths vs. 1.5 shaft widths, p=0.40), shortening (mean difference 0.4 mm, p=0.88), or fixation strategy (intraoperatively-contoured low-profile dual plating 100% vs. 90.9%, p=0.48) between the accelerated vs. traditional groups. Patients in the accelerated cohort (mean 8.7 [95% CI 7.4-10] weeks; range 5.7 weeks to 11.0 weeks) returned to play significantly more quickly than those in the traditional cohort (mean 13.0 [95% CI 11.6-14.4] weeks; range 10.9 weeks to 18 weeks) (p<0.001). There were no refractures in either group (0.0% vs. 0.0%, p>0.99). Similarly, there were no differences in infection (0.0% vs. 0.0%, p>0.99) or wound complications (0.0% vs. 0.0%, p>0.99). Removal of hardware occurred in 16.7% of patients in the accelerated group and 27.3% of patients in the traditional group (p=0.64).
Conclusions:
In this first study to investigate the safety of an accelerated RTP timeline following ORIF of adolescent midshaft clavicle fractures, accelerated RTP was not associated with an increased risk of refracture or other complications. The mean time to RTP in the accelerated RTP group was 8.7 weeks, with patients being cleared to RTP as quickly as 5.7 weeks postoperatively. These data suggest that adolescent patients undergoing anatomic ORIF of midshaft clavicle fractures with low-profile intraoperatively-contoured low profile dual plates may be able RTP more quickly than previously thought. Replication of these results in additional cohorts and evaluation of even earlier RTP timelines (e.g., 4-6 weeks) would be beneficial before accelerated RTP becomes a relative indication for ORIF of midshaft clavicle fractures in adolescents.