Superiority Of Suture Endobutton Augmentation In Type 2b Clavicle Fractures Fixatıon Using Locking Plate
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Abstract Purpose Instability in distal clavicle fractures with impaired integrity of the CC ligament poses a serious risk for nonunion, necessitating surgical intervention. Despite a consensus on the need for surgery in cases of unstable distal clavicle fractures, various surgical techniques are available. Aim of this study is to evaluate the radiological and functional outcomes of CC augmentation using the suture endobutton technique for Neer type 2b clavicle fractures. Methods 42 patients who met the criteria for this retrospective study divided into two groups; Group 1 (locking plate with CC augmentation) and Group 2 (locking plate without CC augmentation). Demographic data, the Constant–Murley scores(CS), union time, range of motion, complications, and implant failures during the follow-up period were recorded. Results 13 (31.0%) patients were female and 29 (69.0%) were male.The mean age was 40.5 ± 11.5 years. Significant differences were found in union time (week) (t(40) = − 2.11, p = 0.04) and the 6th-month CS (t(40) = 4.19, P = 0.01). No significant difference was observed in postoperative complications between the groups (p > 0.05). Conclusion CC augmentation with a suture endobutton in type 2b distal clavicle fractures, resulted in more favorable short-term functional and radiological outcomes.
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Superiority Of Suture Endobutton Augmentation In Type 2b Clavicle Fractures Fixatıon Using Locking Plate | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Superiority Of Suture Endobutton Augmentation In Type 2b Clavicle Fractures Fixatıon Using Locking Plate Hilal Yağar, Ceyhun Çağlar, Zeynel Mert Asfuroğlu, Murat Aydın This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4557906/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Instability in distal clavicle fractures with impaired integrity of the CC ligament poses a serious risk for nonunion, necessitating surgical intervention. Despite a consensus on the need for surgery in cases of unstable distal clavicle fractures, various surgical techniques are available. Aim of this study is to evaluate the radiological and functional outcomes of CC augmentation using the suture endobutton technique for Neer type 2b clavicle fractures. Methods 42 patients who met the criteria for this retrospective study divided into two groups; Group 1 (locking plate with CC augmentation) and Group 2 (locking plate without CC augmentation). Demographic data, the Constant–Murley scores(CS), union time, range of motion, complications, and implant failures during the follow-up period were recorded. Results 13 (31.0%) patients were female and 29 (69.0%) were male.The mean age was 40.5 ± 11.5 years. Significant differences were found in union time (week) ( t (40) = − 2.11, p = 0.04) and the 6th-month CS ( t (40) = 4.19, P = 0.01). No significant difference was observed in postoperative complications between the groups ( p > 0.05). Conclusion CC augmentation with a suture endobutton in type 2b distal clavicle fractures, resulted in more favorable short-term functional and radiological outcomes. Distal clavicle fracture coracoclavicular ligament surgical technique locking plate Neer type 2b Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Clavicle fractures are relatively common, comprising approximately 3% of all fractures in adults [ 1 , 2 ] and 16.6–26% of these being distal end fractures [ 1 , 3 , 4 ]. These fractures often result from direct injury, such as a fall on the shoulder, or traumatic events such as traffic accidents or sports injuries [ 1 , 5 ]. The distal end of the clavicle is associated with the coracoclavicular (CC) ligament, which consists of the trapezoid ligament on the lateral side and the conoid ligament on the medial side [ 6 ]. Neer classified distal 1/3 clavicle fractures according to their relationship with the CC ligament [ 6 ]. In 1982, Rockwood divided Neer type 2 fractures into two subgroups. In type 2a distal clavicle fractures, the fracture occurs medial to the CC ligament. Type 2b distal clavicle fractures have two fracture patterns. In the first fracture pattern, the fracture occurs in the center of the CC ligaments and the conoid ligament is torn, whereas the trapezoid ligament remains intact. In the second fracture pattern, the fracture occurs lateral to the CC ligament and the conoid and trapezoid ligaments are torn [ 7 ]. In these fractures, the trapezius muscle displaces the proximal fragment posteriorly, whereas the distal fragment is directed inferiorly with the weight of the arm. Thus, instability develops in both horizontal and vertical directions [ 6 ]. Instability in distal clavicle fractures with impaired integrity of the CC ligament poses a serious risk for nonunion, necessitating surgical intervention [ 8 ]. Despite a consensus on the need for surgery in cases of unstable distal clavicle fractures, various surgical techniques are available. These techniques encompass CC screw application, locking plate applications, hook plate applications, and arthroscopy-assisted surgical treatments [ 9 , 10 , 11 ]. In cases of Neer type 2b fractures with CC disruption, CC augmentation can be performed either independently or in combination with plate applications. Augmentation techniques may involve the use of suture anchors, reinforced sutures, CC screw, suture endobutton fixation, and tendon and ligament reconstructions [ 12 – 15 ]. However, limited studies have investigated the efficacy of CC augmentation in these fractures [ 16 – 18 ]. This study aimed to evaluate the radiological and functional outcomes of CC augmentation using the suture endobutton technique in conjunction with locking plate application for Neer type 2b clavicle fractures. Materials and Methods This study was conducted at the Department of Orthopedics and Traumatology, Omer Halisdemir University, between March 1, 2016, and January 1, 2023. The study protocol was approved by the Institutional Review Board, Faculty of Medicine, Omer Halisdemir University (No: 2023/26). The study was conducted following the principles of the Declaration of Helsinki. This retrospective study compared two groups of patients: Group 1 (locking plate with CC augmentation) and Group 2 (locking plate without CC augmentation). Among these patients, 42 out of 50 met the following inclusion criterias: (a) acute Neer type 2b fractures, (b) internal fixation with distal clavicle locking plate with or without CC suture endobutton fixation, (c) normal shoulder function before injury, (d) regular follow-up of more than 6 months postoperatively, (e) no previous surgery on the same shoulder. Patients with less than 6 months follow-up, chronic injuries, open fractures, presence of arthritis in the shoulder joint, clavicle fractures accompanied by coracoid process fractures, systemic diseases that may affect union (diabetes, hyper-hypothyroidism, etc.), and pathological fractures were excluded from the study. Of these patients, only distal clavicle locking plate application was performed for 23 patients, and a combination of this application with CC augmentation was performed for 19 patients. Data including age, sex, union time, range of motion, complications, and implant failures during the follow-up period were recorded. The Constant–Murley score (CS) [ 19 ] results of the patients in the 6th postoperative month were recorded and compared. The presence of union was determined by evaluating direct radiographs by two board-certified orthopedists. Surgical Technique And Postsurgical Care Group with distal clavicle locking plate with suture endobutton fixation (Group 1) A single dose of prophylactic antibiotic was administered preoperatively. The patient was positioned in the beach chair position under general anesthesia. A standard anterior 6- to 8-cm incision was made over the clavicle. The fracture was reduced, and temporary fixation was achieved with one K-wire. The AC joint was identified, and plate positioning was ensured using a syringe. Then, the locking plate was placed in accordance with the anatomy of the distal fragment to allow for maximum screw engagement. Under fluoroscopic guidance, a guide wire was inserted from the clavicle (posterior to the locking plate), maintaining the coracoid process centrally by engaging the four cortices. (Fig. 1 ). Following drilling on the guide wire, suture endobutton system was placed on the lower part of the coracoid process and the superior surface of clavicle (posterior to the locking plate) under fluoroscopic guidance. Postoperative radiograhs of the locking plate with suture endobutton system is shown in Fig. 2 . Group with distal clavicle locking plate without suture endobutton fixation (Group 2) A single dose of prophylactic antibiotic was administered preoperatively. The patient was positioned in the beach chair position under general anesthesia. A standard anterior 6- to 8-cm incision was made over the clavicle. The fracture was successfully reduced, and temporary fixation was achieved using a single K-wire. The acromioclavicular (AC) joint was identified, and plate positioning was ensured using a syringe. Then, the locking plate was placed in the distal fragment in accordance with the anatomy, allowing for maximum screw management. Fluoroscopic imaging was conducted, with precautions in place to ensure that the screws did not penetrate the AC joint. (Fig. 3 ) Postsurgical care All patients were instructed to use a shoulder sling for 4 weeks. Isometric and passive shoulder exercises were initiated in the early postoperative period. In the 3rd to 6th weeks, patients started engaging in active and active-assisted range of motion exercises. Strengthening exercises were initiated after the 8th week. Statistical analysis Statistical analysis was performed using the SPSS version 25.0 software (IBM Corp., NY, USA). Descriptive data were presented as mean ± standard deviation, median (min–max), or number and frequency, as appropriate. The continuous data and categorical data were compared using the chi square test and independent-sample t test, respectively. A p value < 0.05 indicated a statistically significant difference. Results In the study group, 13 (31.0%) patients were female and 29 (69.0%) were male. Their ages ranged from 21 to 61 years, with a mean of 40.5 (± 11.5) years and a median of 42.5 years. No significant difference was observed between the right and left sides and sexes in terms of groups ( p > 0.05 for each). The sex and side information of the patients included in the study is provided in Table 1 . Table 1 Sex and side information of the patients included in the study Characteristics n (%) Groups Statistical analysis Chi square; P value Group 1 n (%) Group 2 n (%) Sex Female 13 (31.0) 7 (53.8) 6 (46.2) 0.172; 0.678 Male 29 (69.0) 12 (41.4) 17 (58.6) Side Right 26 (61.9) 13 (50.0) 13 (50.0) 0.222; 0.638 Left 16 (38.1) 6 (37.5) 10 (62.5) Total 42 (100.0) 19 (45.2) 23 (54.8) The result of the t test analysis indicated a significant difference in union time (week) ( t (40) = − 2.11, p = 0.04) and 6th-month CS ( t (40) = 4.19, p = 0.01). According to these results, Group 1 exhibited a shorter duration of union and higher scores for the CS in the 6th month, compared with the plate group. No significant difference was found between the groups in the variables of anterior flexion ( t (40) = 0.76, p = 0.45), external rotation ( t (40) = − 0.02, p = 0.98), and age ( t (40) = − 0.24, p = 0.81). The demographic data, radiological findings, and clinical results of the patients included in the study are presented in Table 2 . Table 2 Demographic data, radiological findings, and clinical results of the patients included in this study Group M, SD t value p value Age Group 1 40.00 ± 12.26 –0.24 0.81 Group 2 40.87 ± 11.09 Union time (week) Group 1 7.37 ± 1.30 –02.11 0.04 Group 2 8.52 ± 2.06 Anterior flexion Group 1 158.95 ± 11.49 0.76 0.45 Group 2 155.22 ± 18.55 External rotation Group 1 69.47 ± 15.80 –0.02 0.81 Group 2 69.57 ± 12.60 Constant score Group 1 95.37 ± 3.05 4.19 0.01 Group 2 90.91 ± 3.70 No significant difference was observed in postoperative complications between the groups ( p > 0.05). Postoperative complications developed in six patients with only locking plate application. Implant failure occurred in two patients, leading to implant revision. Two patients experienced skin irritation. One patient exhibited late union, which was achieved in the 14th week. In the CC augmentation group, complications occurred in three patients, with implant failure in one patient. The locking plate failed in this patient, but the suture endobutton system remained stable, resulting in a 2-mm increase in CC distance. Union and good shoulder function were achieved without reoperation. (Fig. 4 ). Late union was observed in one patient, with union achieved in the 12th week. One patient experienced an early superficial infection and responded to debridement and antibiotic treatment. All patients achieved union, and no other serious complications were encountered. The number of complications in the study patients is presented in Table 3 . Table 3 Number of complications in the patients included in this study Characteristics n (%) Group p value Group 1 n (%) Group 2 n (%) Complication Yes 9 (21.4) 3 (33.3) 6 (66.7) > 0.05 No 33 (78.6) 16 (48.5) 17 (51.5) Discussion This study was novel in comparing the short-term results of CC augmentation in type 2b distal clavicle fracture fixation using a distal clavicle locking plate. Very few studies have demonstrated the biomechanical effectiveness of CC augmentation in unstable distal clavicle fractures. In a biomechanical study on cadavers, Madsen et al. evaluated the effectiveness of CC augmentation besides locking plate application against cyclic load. CC fixation adds stability to type 2b distal clavicle fractures fixed with a plate and screws when loaded to failure [ 20 ]. So biomechanical studies shows CC augmentation provides a more stable fixation. In the present study this might lead to better functional results in the short term by allowing faster rehabilitation and accelerating the union process. In a cohort study involving 18 patients, Cho et al. performed fixation of Neer type 2b clavicle fractures by applying only suture endobutton and obtained a high union rate (94.4%) after 6 months [ 21 ]. Vikas et al. used one endobutton and No. 2 fiber wire for CC augmentation after pre-contoured locking distal clavicle plate application in distal clavicle fractures in 32 patients with CC disruption. They reported that union was achieved in all patients in an average of 11 ± 2.8 weeks (18). In a retrospective series of 12 patients, Han et al. applied CC augmentation with a suture anchor to the coracoid process besides the locking plate. In 12th week, union was achieved in all patients [ 22 ]. The present study reported union in all fractures in both groups and demonstrated faster union in patients who underwent CC augmentation. Esenyel et al. performed CC fixation with percutaneous lag screw application in type 2 distal clavicle fractures in a series of 16 patients. They performed hardware removal after union was achieved and found no postoperative limitation of joint motion [ 10 ]. In a retrospective study conducted with 24 patients, Perskin et al. performed CC augmentation with a locked distal anatomic plate and suture endobutton in Neer type 2b clavicle fractures. They observed radiological union in 96% of the patients and found a mean shoulder forward elevation of 168 degrees (120–180 degrees) and a mean external rotation of 57 degrees (20–90 degrees) [ 16 ]. In the present study, the range of motion was similar to that reported in the literature, and no significant difference was found in both groups. In a study involving 28 patients, Yang et al. achieved reduction by wrapping a Mersilene tape under the coracoid in unstable distal clavicle fractures and securing it on the clavicle. They evaluated these patients using the University of California Los Angeles shoulder rating score. The researchers reported excellent results in 20 patients and good results in 8 patients [ 23 ]. Seyhan et al. conducted a study with 36 patients, comparing 3 different CC augmentation techniques. In the first group, a tension band was applied to the fracture line with a K-wire, and the Ethibond suture was passed under the coracoid and tied on the clavicle for CC augmentation. In the second group, a coracoclavicular lag screw was applied over the locked plate for CC augmentation. In the third group, CC augmentation was performed using the suture endobutton technique over the locked plate. Among these three groups, the group in which augmentation was performed with suture endobutton had higher CSs in the 3rd, 6th, and 12th months [ 17 ]. Hohmann et al. applied a distal radius locking plate to unstable distal clavicle fractures and performed CC augmentation with a suture endobutton from the posterior of the plate. They demonstrated that a sufficient number of screws could be inserted in distal fractures with small fragments with this technique and reported that they obtained high constant, the disabilities of the arm, shoulder and hand score (DASH), and shoulder pain and disability index (SPADI) scores in the 1st-year follow-up [ 24 ]. In a retrospective study conducted with 23 patients, Salazar et al. comparatively evaluated the efficacy of CC augmentation using an anchor besides locking plate application in Neer type 2 and type 5 distal clavicle fractures. They obtained similar Quick-DASH scores in both patient groups in the study (25). Wang et al. used a titanium cable as a CC augmentation technique in a prospective study with 36 patients. Following the locking plate application, the cable was passed under the coracoid and fixed on the upper surface of the plate. They compared the CSs of these patients in the 12th month with hook plate application and obtained statistically significant results [ 26 ]. Yan et al. compared hook plate application with gracilis tendon and CC ligament reconstruction with a suture anchor in a prospective study performed with 42 patients. The researchers showed that better CSs were obtained in the reconstruction group in the short term [ 27 ]. In the present study, better CSs were obtained in the CC augmentation group in the 6th-month follow-up. In a retrospective study involving 25 patients, Shin et al. applied a contoured locking plate without CC augmentation in patients with Neer type 2 clavicle fracture. They found an average 10% increase in CC distance on the fracture side compared with those without fractures. However, they reported that this radiological difference did not affect functional outcomes [ 28 ]. Singh et al. conducted another retrospective study with 74 patients, evaluating complications in Neer type 2 and type 5 clavicle fractures. They found that hook plates had a higher risk of complications and reoperation than contoured plates and suture endobuttons. They recommended avoiding the routine use of hook plates. The researchers also noted that using transosseous sutures alone led to more joint stiffness and fewer complications [ 29 ]. A meta-analysis reported a higher frequency of major complications after hook plate fixation than other treatment modalities, with no significant difference in minor complications [ 30 ]. The present study indicated that CC augmentation did not influence the development of complications. Furthermore, the surgical technique used in this study allowed successful union without needing revision surgery, even if implant failure develops. In cases requiring implant removal such as irritation, it was possible to safely remove the plate, including in the early period, without removing the suture endobutton. Limitations This study had some limitations, including its retrospective nature, being confined to a single center with a limited number of patients, and the lack of randomization. In this study, only short-term results were evaluated, despite the patients having longer follow-up periods. Long-term functional results after union were not evaluated in this study. Multicenter randomized controlled studies and biomechanical investigations are urgently needed on this subject. Conclusion In conclusion, this study demonstrated that CC augmentation with a suture endobutton, besides applying a locking plate in type 2b distal clavicle fractures, resulted in more favorable short-term functional and radiological outcomes. 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Stegeman SA, Nacak H, Huvenaars KH, Stijnen T, Krijnen P, Schipper IB. Surgical treatment of Neer type-II fractures of the distal clavicle: a meta-analysis. Acta Orthop. 2013;84(2):184–90. 10.3109/17453674.2013.786637 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4557906","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318751234,"identity":"ffb57fbe-3214-4718-aa18-21d806dacda0","order_by":0,"name":"Hilal Yağar","email":"","orcid":"","institution":"Niğde Ömer Halisdemir University","correspondingAuthor":false,"prefix":"","firstName":"Hilal","middleName":"","lastName":"Yağar","suffix":""},{"id":318751235,"identity":"d8c0b6de-fc76-4e6c-846e-f19055b545e0","order_by":1,"name":"Ceyhun Çağlar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYHACNijN3MDAUHEAzDzwgDgtjEAtZw4w8IC0JBCthbENooUBnxb+9h6zx7w7GOT5+xc2fq6cd0fOXuzwQ6AtdnK6Ddi1SJw5Y27Me4bBcMaNh82SZ7c9M+aRTjMAakk2NjuAXYuBRI6ZNG8b0CU3DjZINm47nNgjnQDSciBxGy4t8m8gWuRvHGz+2TgHpCX9A34tEjwQLQbnG9skGxtAWnLw2yJxJq1Mcm6bhOHGG4xtlg3HDhvz3M4pOJBggNsv/O2Ht0m8bbORlzt/+PDNhprDcuyz0zd/+FBhJ4dLCwMDhwHIMiBKQHEwLuUgwP4Aah9OQ0fBKBgFo2CkAwAbq2KDG59pmwAAAABJRU5ErkJggg==","orcid":"","institution":"Ankara Yıldırım Beyazıt University","correspondingAuthor":true,"prefix":"","firstName":"Ceyhun","middleName":"","lastName":"Çağlar","suffix":""},{"id":318751236,"identity":"ec21861b-672c-4ffb-a99e-ab8f559584bb","order_by":2,"name":"Zeynel Mert Asfuroğlu","email":"","orcid":"","institution":"Mersin University","correspondingAuthor":false,"prefix":"","firstName":"Zeynel","middleName":"Mert","lastName":"Asfuroğlu","suffix":""},{"id":318751237,"identity":"405370ae-fd0a-45f0-9a7b-74ba4ab5aceb","order_by":3,"name":"Murat Aydın","email":"","orcid":"","institution":"Pendik Yüzyıl Hospital","correspondingAuthor":false,"prefix":"","firstName":"Murat","middleName":"","lastName":"Aydın","suffix":""}],"badges":[],"createdAt":"2024-06-10 12:07:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4557906/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4557906/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59525364,"identity":"830e571d-fcfe-4ad2-a96b-6624f1fd094e","added_by":"auto","created_at":"2024-07-02 20:52:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1573923,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative view of locking plate application with CC augmentation\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4557906/v1/d9113ca1fa6b313215bc5d58.jpg"},{"id":59524188,"identity":"7e6be076-8d3e-40ed-b412-b138567a1659","added_by":"auto","created_at":"2024-07-02 20:44:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":169142,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative radiograhs of the locking plate with suture endobutton system\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4557906/v1/08092ac5a1b2896673e5ad64.jpg"},{"id":59524185,"identity":"aed7cc25-578b-43f5-bad7-46b7668ac617","added_by":"auto","created_at":"2024-07-02 20:44:09","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":250130,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative radiograhs of the clavicle fixated with locking plate\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4557906/v1/9d342fbd8698c69188732888.jpg"},{"id":59524186,"identity":"690f5023-105e-4a2a-9329-956ec69c21f1","added_by":"auto","created_at":"2024-07-02 20:44:09","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":463537,"visible":true,"origin":"","legend":"\u003cp\u003eImplant failure of locking plate with CC augmentation\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4557906/v1/f7600846c3d7f89366b4c831.jpg"},{"id":67106494,"identity":"4237cbaa-cb59-4960-a52b-7c91928063e6","added_by":"auto","created_at":"2024-10-21 08:54:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2863698,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4557906/v1/4141fc93-6958-4ce0-83a0-990d240dde04.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Superiority Of Suture Endobutton Augmentation In Type 2b Clavicle Fractures Fixatıon Using Locking Plate","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClavicle fractures are relatively common, comprising approximately 3% of all fractures in adults [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and 16.6\u0026ndash;26% of these being distal end fractures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These fractures often result from direct injury, such as a fall on the shoulder, or traumatic events such as traffic accidents or sports injuries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe distal end of the clavicle is associated with the coracoclavicular (CC) ligament, which consists of the trapezoid ligament on the lateral side and the conoid ligament on the medial side [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Neer classified distal 1/3 clavicle fractures according to their relationship with the CC ligament [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In 1982, Rockwood divided Neer type 2 fractures into two subgroups. In type 2a distal clavicle fractures, the fracture occurs medial to the CC ligament. Type 2b distal clavicle fractures have two fracture patterns. In the first fracture pattern, the fracture occurs in the center of the CC ligaments and the conoid ligament is torn, whereas the trapezoid ligament remains intact. In the second fracture pattern, the fracture occurs lateral to the CC ligament and the conoid and trapezoid ligaments are torn [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In these fractures, the trapezius muscle displaces the proximal fragment posteriorly, whereas the distal fragment is directed inferiorly with the weight of the arm. Thus, instability develops in both horizontal and vertical directions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInstability in distal clavicle fractures with impaired integrity of the CC ligament poses a serious risk for nonunion, necessitating surgical intervention [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite a consensus on the need for surgery in cases of unstable distal clavicle fractures, various surgical techniques are available. These techniques encompass CC screw application, locking plate applications, hook plate applications, and arthroscopy-assisted surgical treatments [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn cases of Neer type 2b fractures with CC disruption, CC augmentation can be performed either independently or in combination with plate applications. Augmentation techniques may involve the use of suture anchors, reinforced sutures, CC screw, suture endobutton fixation, and tendon and ligament reconstructions [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, limited studies have investigated the efficacy of CC augmentation in these fractures [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to evaluate the radiological and functional outcomes of CC augmentation using the suture endobutton technique in conjunction with locking plate application for Neer type 2b clavicle fractures.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study was conducted at the Department of Orthopedics and Traumatology, Omer Halisdemir University, between March 1, 2016, and January 1, 2023. The study protocol was approved by the Institutional Review Board, Faculty of Medicine, Omer Halisdemir University (No: 2023/26). The study was conducted following the principles of the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eThis retrospective study compared two groups of patients: Group 1 (locking plate with CC augmentation) and Group 2 (locking plate without CC augmentation). Among these patients, 42 out of 50 met the following inclusion criterias: (a) acute Neer type 2b fractures, (b) internal fixation with distal clavicle locking plate with or without CC suture endobutton fixation, (c) normal shoulder function before injury, (d) regular follow-up of more than 6 months postoperatively, (e) no previous surgery on the same shoulder. Patients with less than 6 months follow-up, chronic injuries, open fractures, presence of arthritis in the shoulder joint, clavicle fractures accompanied by coracoid process fractures, systemic diseases that may affect union (diabetes, hyper-hypothyroidism, etc.), and pathological fractures were excluded from the study.\u003c/p\u003e \u003cp\u003eOf these patients, only distal clavicle locking plate application was performed for 23 patients, and a combination of this application with CC augmentation was performed for 19 patients. Data including age, sex, union time, range of motion, complications, and implant failures during the follow-up period were recorded. The Constant\u0026ndash;Murley score (CS) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] results of the patients in the 6th postoperative month were recorded and compared. The presence of union was determined by evaluating direct radiographs by two board-certified orthopedists.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Technique And Postsurgical Care\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eGroup with distal clavicle locking plate with suture endobutton fixation (Group 1)\u003c/h2\u003e \u003cp\u003eA single dose of prophylactic antibiotic was administered preoperatively. The patient was positioned in the beach chair position under general anesthesia. A standard anterior 6- to 8-cm incision was made over the clavicle. The fracture was reduced, and temporary fixation was achieved with one K-wire. The AC joint was identified, and plate positioning was ensured using a syringe. Then, the locking plate was placed in accordance with the anatomy of the distal fragment to allow for maximum screw engagement. Under fluoroscopic guidance, a guide wire was inserted from the clavicle (posterior to the locking plate), maintaining the coracoid process centrally by engaging the four cortices. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Following drilling on the guide wire, suture endobutton system was placed on the lower part of the coracoid process and the superior surface of clavicle (posterior to the locking plate) under fluoroscopic guidance. Postoperative radiograhs of the locking plate with suture endobutton system is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eGroup with distal clavicle locking plate without suture endobutton fixation (Group 2)\u003c/h2\u003e \u003cp\u003eA single dose of prophylactic antibiotic was administered preoperatively. The patient was positioned in the beach chair position under general anesthesia. A standard anterior 6- to 8-cm incision was made over the clavicle. The fracture was successfully reduced, and temporary fixation was achieved using a single K-wire. The acromioclavicular (AC) joint was identified, and plate positioning was ensured using a syringe. Then, the locking plate was placed in the distal fragment in accordance with the anatomy, allowing for maximum screw management. Fluoroscopic imaging was conducted, with precautions in place to ensure that the screws did not penetrate the AC joint. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePostsurgical care\u003c/h2\u003e \u003cp\u003eAll patients were instructed to use a shoulder sling for 4 weeks. Isometric and passive shoulder exercises were initiated in the early postoperative period. In the 3rd to 6th weeks, patients started engaging in active and active-assisted range of motion exercises. Strengthening exercises were initiated after the 8th week.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using the SPSS version 25.0 software (IBM Corp., NY, USA). Descriptive data were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median (min\u0026ndash;max), or number and frequency, as appropriate. The continuous data and categorical data were compared using the chi square test and independent-sample \u003cem\u003et\u003c/em\u003e test, respectively. A \u003cem\u003ep\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated a statistically significant difference.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the study group, 13 (31.0%) patients were female and 29 (69.0%) were male. Their ages ranged from 21 to 61 years, with a mean of 40.5 (\u0026plusmn;\u0026thinsp;11.5) years and a median of 42.5 years. No significant difference was observed between the right and left sides and sexes in terms of groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for each). The sex and side information of the patients included in the study is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSex and side information of the patients included in the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStatistical analysis\u003c/p\u003e \u003cp\u003eChi square; \u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.172; 0.678\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (41.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (58.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (61.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.222; 0.638\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (38.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (62.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (45.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (54.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe result of the \u003cem\u003et\u003c/em\u003e test analysis indicated a significant difference in union time (week) (\u003cem\u003et\u003c/em\u003e(40) = \u0026minus;\u0026thinsp;2.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04) and 6th-month CS (\u003cem\u003et\u003c/em\u003e(40)\u0026thinsp;=\u0026thinsp;4.19, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01). According to these results, Group 1 exhibited a shorter duration of union and higher scores for the CS in the 6th month, compared with the plate group. No significant difference was found between the groups in the variables of anterior flexion (\u003cem\u003et\u003c/em\u003e(40)\u0026thinsp;=\u0026thinsp;0.76, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.45), external rotation (\u003cem\u003et\u003c/em\u003e(40) = \u0026minus;\u0026thinsp;0.02, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.98), and age (\u003cem\u003et\u003c/em\u003e(40) = \u0026minus;\u0026thinsp;0.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.81). The demographic data, radiological findings, and clinical results of the patients included in the study are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data, radiological findings, and clinical results of the patients included in this study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eM, SD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e40.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026ndash;0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e40.87\u0026thinsp;\u0026plusmn;\u0026thinsp;11.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUnion time (week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026ndash;02.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.52\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnterior flexion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e158.95\u0026thinsp;\u0026plusmn;\u0026thinsp;11.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e155.22\u0026thinsp;\u0026plusmn;\u0026thinsp;18.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExternal rotation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e69.47\u0026thinsp;\u0026plusmn;\u0026thinsp;15.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026ndash;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e69.57\u0026thinsp;\u0026plusmn;\u0026thinsp;12.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eConstant score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e95.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e90.91\u0026thinsp;\u0026plusmn;\u0026thinsp;3.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNo significant difference was observed in postoperative complications between the groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Postoperative complications developed in six patients with only locking plate application. Implant failure occurred in two patients, leading to implant revision. Two patients experienced skin irritation. One patient exhibited late union, which was achieved in the 14th week. In the CC augmentation group, complications occurred in three patients, with implant failure in one patient. The locking plate failed in this patient, but the suture endobutton system remained stable, resulting in a 2-mm increase in CC distance. Union and good shoulder function were achieved without reoperation. (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Late union was observed in one patient, with union achieved in the 12th week. One patient experienced an early superficial infection and responded to debridement and antibiotic treatment. All patients achieved union, and no other serious complications were encountered. The number of complications in the study patients is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of complications in the patients included in this study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17 (51.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was novel in comparing the short-term results of CC augmentation in type 2b distal clavicle fracture fixation using a distal clavicle locking plate. Very few studies have demonstrated the biomechanical effectiveness of CC augmentation in unstable distal clavicle fractures. In a biomechanical study on cadavers, Madsen et al. evaluated the effectiveness of CC augmentation besides locking plate application against cyclic load. CC fixation adds stability to type 2b distal clavicle fractures fixed with a plate and screws when loaded to failure [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. So biomechanical studies shows CC augmentation provides a more stable fixation. In the present study this might lead to better functional results in the short term by allowing faster rehabilitation and accelerating the union process.\u003c/p\u003e \u003cp\u003eIn a cohort study involving 18 patients, Cho et al. performed fixation of Neer type 2b clavicle fractures by applying only suture endobutton and obtained a high union rate (94.4%) after 6 months [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Vikas et al. used one endobutton and No. 2 fiber wire for CC augmentation after pre-contoured locking distal clavicle plate application in distal clavicle fractures in 32 patients with CC disruption. They reported that union was achieved in all patients in an average of 11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 weeks (18). In a retrospective series of 12 patients, Han et al. applied CC augmentation with a suture anchor to the coracoid process besides the locking plate. In 12th week, union was achieved in all patients [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The present study reported union in all fractures in both groups and demonstrated faster union in patients who underwent CC augmentation.\u003c/p\u003e \u003cp\u003eEsenyel et al. performed CC fixation with percutaneous lag screw application in type 2 distal clavicle fractures in a series of 16 patients. They performed hardware removal after union was achieved and found no postoperative limitation of joint motion [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In a retrospective study conducted with 24 patients, Perskin et al. performed CC augmentation with a locked distal anatomic plate and suture endobutton in Neer type 2b clavicle fractures. They observed radiological union in 96% of the patients and found a mean shoulder forward elevation of 168 degrees (120\u0026ndash;180 degrees) and a mean external rotation of 57 degrees (20\u0026ndash;90 degrees) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In the present study, the range of motion was similar to that reported in the literature, and no significant difference was found in both groups.\u003c/p\u003e \u003cp\u003eIn a study involving 28 patients, Yang et al. achieved reduction by wrapping a Mersilene tape under the coracoid in unstable distal clavicle fractures and securing it on the clavicle. They evaluated these patients using the University of California Los Angeles shoulder rating score. The researchers reported excellent results in 20 patients and good results in 8 patients [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Seyhan et al. conducted a study with 36 patients, comparing 3 different CC augmentation techniques. In the first group, a tension band was applied to the fracture line with a K-wire, and the Ethibond suture was passed under the coracoid and tied on the clavicle for CC augmentation. In the second group, a coracoclavicular lag screw was applied over the locked plate for CC augmentation. In the third group, CC augmentation was performed using the suture endobutton technique over the locked plate. Among these three groups, the group in which augmentation was performed with suture endobutton had higher CSs in the 3rd, 6th, and 12th months [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Hohmann et al. applied a distal radius locking plate to unstable distal clavicle fractures and performed CC augmentation with a suture endobutton from the posterior of the plate. They demonstrated that a sufficient number of screws could be inserted in distal fractures with small fragments with this technique and reported that they obtained high constant, the disabilities of the arm, shoulder and hand score (DASH), and shoulder pain and disability index (SPADI) scores in the 1st-year follow-up [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In a retrospective study conducted with 23 patients, Salazar et al. comparatively evaluated the efficacy of CC augmentation using an anchor besides locking plate application in Neer type 2 and type 5 distal clavicle fractures. They obtained similar Quick-DASH scores in both patient groups in the study (25). Wang et al. used a titanium cable as a CC augmentation technique in a prospective study with 36 patients. Following the locking plate application, the cable was passed under the coracoid and fixed on the upper surface of the plate. They compared the CSs of these patients in the 12th month with hook plate application and obtained statistically significant results [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Yan et al. compared hook plate application with gracilis tendon and CC ligament reconstruction with a suture anchor in a prospective study performed with 42 patients. The researchers showed that better CSs were obtained in the reconstruction group in the short term [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In the present study, better CSs were obtained in the CC augmentation group in the 6th-month follow-up.\u003c/p\u003e \u003cp\u003eIn a retrospective study involving 25 patients, Shin et al. applied a contoured locking plate without CC augmentation in patients with Neer type 2 clavicle fracture. They found an average 10% increase in CC distance on the fracture side compared with those without fractures. However, they reported that this radiological difference did not affect functional outcomes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Singh et al. conducted another retrospective study with 74 patients, evaluating complications in Neer type 2 and type 5 clavicle fractures. They found that hook plates had a higher risk of complications and reoperation than contoured plates and suture endobuttons. They recommended avoiding the routine use of hook plates. The researchers also noted that using transosseous sutures alone led to more joint stiffness and fewer complications [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A meta-analysis reported a higher frequency of major complications after hook plate fixation than other treatment modalities, with no significant difference in minor complications [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The present study indicated that CC augmentation did not influence the development of complications. Furthermore, the surgical technique used in this study allowed successful union without needing revision surgery, even if implant failure develops. In cases requiring implant removal such as irritation, it was possible to safely remove the plate, including in the early period, without removing the suture endobutton.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study had some limitations, including its retrospective nature, being confined to a single center with a limited number of patients, and the lack of randomization. In this study, only short-term results were evaluated, despite the patients having longer follow-up periods. Long-term functional results after union were not evaluated in this study. Multicenter randomized controlled studies and biomechanical investigations are urgently needed on this subject.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study demonstrated that CC augmentation with a suture endobutton, besides applying a locking plate in type 2b distal clavicle fractures, resulted in more favorable short-term functional and radiological outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConcept: H.Y., Data curation: H.Y.,M.A., Formal analysis: H.Y., C.\u0026Ccedil;., Investigation: H.Y.,M.A., Methodology: H.Y., M.A., Supervision: M.A., Z.M.A., Visualization: H.Y., Writing manuscript: H.Y., Critical review: C.\u0026Ccedil;., Z.M.A.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res. 1994;1:300:127\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCourt-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.injury.2006.04.130\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2006.04.130\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNowak J, Mallmin H, Larsson S. The aetiology and epidemiology of clavicular fractures: a prospective study during a two-year period. 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Orthop Traumatol Surg Res. 2019;105(5):853\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.otsr.2019.03.012\u003c/span\u003e\u003cspan address=\"10.1016/j.otsr.2019.03.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStegeman SA, Nacak H, Huvenaars KH, Stijnen T, Krijnen P, Schipper IB. Surgical treatment of Neer type-II fractures of the distal clavicle: a meta-analysis. Acta Orthop. 2013;84(2):184\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/17453674.2013.786637\u003c/span\u003e\u003cspan address=\"10.3109/17453674.2013.786637\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Distal clavicle fracture, coracoclavicular ligament, surgical technique, locking plate, Neer type 2b","lastPublishedDoi":"10.21203/rs.3.rs-4557906/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4557906/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eInstability in distal clavicle fractures with impaired integrity of the CC ligament poses a serious risk for nonunion, necessitating surgical intervention. Despite a consensus on the need for surgery in cases of unstable distal clavicle fractures, various surgical techniques are available. Aim of this study is to evaluate the radiological and functional outcomes of CC augmentation using the suture endobutton technique for Neer type 2b clavicle fractures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e42 patients who met the criteria for this retrospective study divided into two groups; Group 1 (locking plate with CC augmentation) and Group 2 (locking plate without CC augmentation). Demographic data, the Constant\u0026ndash;Murley scores(CS), union time, range of motion, complications, and implant failures during the follow-up period were recorded.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e13 (31.0%) patients were female and 29 (69.0%) were male.The mean age was 40.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 years. Significant differences were found in union time (week) (\u003cem\u003et\u003c/em\u003e(40) = \u0026minus;\u0026thinsp;2.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04) and the 6th-month CS (\u003cem\u003et\u003c/em\u003e(40)\u0026thinsp;=\u0026thinsp;4.19, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01). No significant difference was observed in postoperative complications between the groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCC augmentation with a suture endobutton in type 2b distal clavicle fractures, resulted in more favorable short-term functional and radiological outcomes.\u003c/p\u003e","manuscriptTitle":"Superiority Of Suture Endobutton Augmentation In Type 2b Clavicle Fractures Fixatıon Using Locking Plate","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-02 20:44:04","doi":"10.21203/rs.3.rs-4557906/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2e740a46-6672-4265-9054-654132acc1a3","owner":[],"postedDate":"July 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T08:54:04+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-02 20:44:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4557906","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4557906","identity":"rs-4557906","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}
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