Clavicle reduction osteotomies are an effective procedure for changing the width or wide shape of the shoulders. It is a conceptually straightforward procedure at its most basic level is linear in nature….remove a segment of the clavicle and putting it back together will move the shoulders inward. Its effectiveness depends on getting the two ends of the bone back together, aligned and in as close contact as possible. This sounds simple but executing it successfully is not.
Once the clavicle bone segment is removed an obvious gap occurs. But it is not a stable gap and is now associated with a flail shoulder. The weight of the shoulder and the pull of the pectoralis major muscle draws the distal bone segment inward and down.To get the two segments properly aligned it takes one assistant to lift the shoulder and hold it inward, another assistant is needed to put the two ends together as close as possible and then a third person to apply 3.5mm upper plate with a bicortical screw on each side. Thereafter the rest of the screws (two additional ones each side) can be placed with less assistance.
Depending upon how close the two bone segments are put together partially controls whether an anterior smaller stabilizing plate is needed. If there is a very tight apposition, which is always the goal, and the bone is thin then an anterior plate may not be used. But if there is some slight gap, which can easily occur with the angle of the two bone cuts, then the anterior plate adds stabilization value.
The larger superior plate protects against arm abduction and flexion movements while the anterior plate helps protect against the forces placed from extension and medial/lateral rotation. While its use seems to be of obvious benefit one also has to be mindful of the metal to bone ratio in a restricted osteotomy site. This is not like a fracture where the break line is spread over a much longer area of the bone and, as a result, the plate fixation with screws is similarly spread out. While the anterior plate has its stabilization benefits one must also be wary of a devascularizing effect. So its application is a balance betwee ensuring stabilization so the bone can heal vs too much metal close to the osteotomy line which could adversely affect healing.
Narrowing the shoulders requires taking two major bones, shortening their lengths by resection putting them back together….all using incisions that are less than 4cms per side. While the effects of the surgery is immediate the ultimate success of the procedure requires complete bony healing across the osteotomy line. There are numerous factors that go into the healing of the osteotomy site from bony end approximation, stabilization across the united ends, adequate bone vascularity and postoperative limited range of arm motion. The anterior plate is an ancillary technique that has advantages and disadvantages whose use is decided on an individual patient basis.
Dr. Barry Eppley
World-Renowned Plastic Surgeon