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Clavicle reduction is a very effective technique for a shoulder narrowing effect. And in many aspects it is a straightforward procedure…remove a segment of bone, put it back together and let it heal. The result is instantaneous as the surgery site is on the opposite end of the clavicle where the effect is going to be seen. As a result swelling does not reach the target site (outer shoulders) and thus the effects of shortening the clavicle are immediately apparent.

Since the result is never in doubt from removing the bone, attention is paid to both the amount of bone removed (how much of an effect will it make) and making sure that a bony union is achieved. Failure of the latter poses a big postoperative problem, for which re-operative surgery can solve, but it is a problem best avoided given the value that arm movement plays in our everyday lives.

Rigid fixation using plates and screws is an essential part of the clavicle bone healing process. Making sure the titanium fixation is rigid enough is the first part of this equation. As a general rule the clavicle can be satisfactorily secured with 2.7 to 3.5mm plates. Because of the relatively thin soft tissue cover of the bone the smaller 2.7mm plate profile is used. The most important location for a fixation plate is on the superior or upper edge of the bone.

But an integral element of the application of the plate and screws is getting as perfect as possible as possible alignment of the two bone ends. Because the two bone cuts are made at slightly different locations on the bone there will be some minor discrepancies in the cross-sectional thicknesses/diameter between them. This is an irrelevant issue as long as the bone are in intimate apposition. There needs to be no gap between them as much as possible. Working through a small incision this is not as easy as it may look. It really takes two people to get this type of alignment, one to hold it optimally together and the other to apply the plate and screws.

Once the major superior plate is applied, despite optimal alignment, I apply another smaller plate on the anterior surface. Whether this plate is absolutely essential is not known but it resists another direction of pull on the bone during the healing process. Given any risk of non-union I feel it is prudent to do so.

While an operation may be conceptually simple to perform, the execution of it still requires attention to detail. In shoulder narrowing surgery plate and screw fixation alone is not enough to ensure a bony non-union. Optimal alignment of the two bone segments with a nearly invisible gap between them is necessary for rapid healing and early ossification across the two cut bone ends.      

Dr. Barry Eppley

Indianapolis, Indiana

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