Comparing two autologous bone grafting techniques to treat clavicular midshaft atrophic nonunion: a retrospective study

Ma et al. Journal of Orthopaedics and Traumatology (2025) 26:11 https://doi.org/10.1186/s10195-025-00828-z Journal of Orthopaedics and Traumatology Open Access ORIGINAL ARTICLE Comparing two autologous bone grafting techniques to treat clavicular midshaft atrophic nonunion: a retrospective study Teng Ma1†, Qiang Huang1†, Chaofeng Wang1†, Cheng Ren1, Yibo Xu1, Hua Lin1, Kun Zhang1, Congming Zhang1* and Zhao Li1* Abstract Background Open reduction, superior plate (SP) fixation, and autologous cancellous granular bone grafting (ACGBG) are common strategies for treating clavicular midshaft atrophic nonunion (CMAN). We aimed to compare the radiological findings and clinical effects of two autologous cancellous bone grafts (ACBGs) and those of single SP fixation, to treat CMAN. Methods This retrospective study comprised 62 patients admitted to our hospital with CMAN (ACGBG with single SP fixation between March 2012 and October 2017, 32 patients; autologous cancellous structured bone grafting [ACSBG] with single SP fixation between November 2017 and May 2021, 30 patients). Patient visual analog scale (VAS) scores for pain and disability of the arm, shoulder, and hand (DASH) scores, obtained preoperatively and at final follow-up, were recorded and analyzed. Statistical differences between the ACGBG and ACSBG groups were assessed using Fisher’s exact and two-sample independent t tests. Results No statistically significant differences were observed between the two groups in terms of patient demographics or the incidence of complications. VAS and DASH scores decreased significantly from the preoperative day to 9 months postoperatively in both groups, but this difference was not statistically significant at final follow-up. However, at 3 and 6 months postoperatively, compared with mean VAS and DASH scores in the ACGBG group, the ACSBG group showed lower pain and dysfunction scores (p < 0.05). The mean fracture healing times were 15.2 (range, 12–20) and 18.6 (range, 12–32) weeks in the ACSBG and ACGBG groups, respectively (p = 0.01). One case of plate breakage occurred in the ACGBG group at 5 months postoperatively, with recovery following ACSBG revision with single SP fixation. Conclusions ACSBG combined with single SP fixation is a promising and effective alternative technique for promoting bone union and postoperative early functional rehabilitation in treating CMAN. Level of evidence Level 3. Keywords Autologous bone grafting, Atrophic nonunion, Revision, Superior plate † Teng Ma, Qiang Huang, and Chaofeng Wang are shared co-first authors. *Correspondence: Congming Zhang Zhao Li 1 Department of Severe and Poly Trauma, Honghui Hospital, Xi’an Jiaotong University, 555 Youyi Road, Xi’an 710054, China Introduction The clavicle is a commonly fractured bone, accounting for 2.6–4% of all adult fractures [1]. Fractures of the midshaft clavicle represent 69–82% of all clavicle fractures [1, 2]. Conventionally, the use of a broad-arm sling or figureof-eight bandaging has been the most frequently used method to treat clavicle fractures [3]. However, the © The Author(s) 2025. 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Journal of Orthopaedics and Traumatology (2025) 26:11 incidence of clavicular nonunion after nonoperative treatment has been reported to be 0.1–5% [4]. In addition, the incidence of nonunion in these fractures increases by up to 2.6–8% after operative treatment [5, 6]. Clavicular nonunion can lead to persistent pain and loss of shoulder function [7]. Compared with acute clavicle fractures, the surgical treatment of clavicle nonunion has a relatively high complication rate and unsatisfactory clinical results, which is a challenge for surgeons [8–10]. Open reduction, superior plate (SP) fixation, and bone grafting allow early recovery and provide good outcomes, and are the most accepted methods for treating clavicle nonunion in patients with atrophic fractures [11]. Autogenous iliac crest bone grafts are considered the gold standard, owing to their osteogenic, osteoconductive, and osteoinductive properties [12]. Cancellous bone is packed into the nonunion gap, which is the most common technique for clavicle nonunion to promote fracture union; however, the incidence of nonunion in long-term follow-up studies has been reported to be 3.1–10.5% [9, 13, 14]. Mechanical instability between the two fractured ends may explain this type of revision failure. Lately, some surgeons have used an additional structured autologous cortical graft as a strut placed under the nonunion site to bridge over the gap and provide mechanical stability for aseptic nonunion of the clavicle [15, 16]. Two studies have reported that, in all but one case of nonunion, solid bone union was achieved at a mean of 14–16 weeks [15, 16]. These studies suggest that enhancing the mechanical stability of both fracture ends is a promising method for treating clavicular nonunion. In recent years, open reduction and single superior plate (SP) fixation and structured bone grafting has been considered to be a standard technique for treating atrophic nonunion of the clavicle in our hospital, which has achieved good clinical outcomes [17]. In this study, we aimed to compare the radiological and clinical results of treating primary clavicular midshaft atrophic nonunion (CMAN) between the autologous cancellous granular bone grafting (ACGBG) and autologous Page 2 of 9 cancellous structured bone grafting (ACSBG) techniques to provide surgeons with an optimal alternative when treating patients with this type of nonunion. Methods Patients Inclusion criteria comprised patients: (i) aged 18–65 years; (ii) who underwent surgery for clavicular midshaft fracture repair at least 9 months prior, for whom the fracture had shown failure to heal for 3 months [18]; (iii) with pain or instability over the local site requiring surgical intervention; and (iv) with sclerosis of the fracture end and no callus formation. Exclusion criteria comprised patients: (i) aged < 18 years or > 65 years; (ii) treated using the ACGBG technique with an intramedullary nail or external fixation; (iii) with local chronic infection of nonunio (...truncated)