Free Vascularized Fibular Graft for Reconstruction of the Lateral Clavicle
Authors: Arenas-Miquelez Antonio , Karargyris Orestis , Olariu Radu , Zumstein Matthias 
Published: October 2019

Update

This article was updated on May 8, 2020, because further assessment of the patient revealed that the outcome worsened over time. Specifically, the patient had symptoms over the clavicle as well as donor-side morbidity at the fibula and, as a result, underwent multiple reoperations at another institution. In view of the ultimate outcome for the patient, the published data did not reflect the ultimate result but rather represented just an intermediate result. These findings have necessitated a number of changes throughout the text to more accurately describe the outcome.

On page 1, in the Abstract, the sentence that had read “At 4 years of follow-up, the patient had experienced resolution of painful symptoms with a Constant-Murley score of 72” now reads “At 4 years of follow-up, the patient had consolidation of the transferred fibula and experienced in the meantime reduction of painful symptoms. However, the patient subsequently had symptoms over the clavicle and donor-site morbidity in the leg, resulting in multiple reoperations.” Also, the sentence that had read “Reconstruction of large, lateral clavicle defects with a free vascularized fibular graft and biplanar stabilization of the AC joint may provide a satisfactory clinical outcome” now reads “Reconstruction of large, lateral clavicle defects with a free vascularized fibular graft and biplanar stabilization of the AC joint may provide only an intermediate satisfactory clinical outcome. However, over time, this outcome can worsen with the development of symptoms over the clavicle as well as donor-site morbidity.” On page 3, the paragraph that had read “At 4 years postoperatively, the radiographs confirmed complete graft consolidation (Fig. 7). Clinically, the neurologic symptoms have resolved, and there was significant reduction of painful symptoms over the midclavicle area, with a Visual Analogue Scale score of 2/10. The operated shoulder presented with a ROM of 165° of elevation and 40° of external rotation, with internal rotation up to T12 vertebra. The patient had a Constant-Murley score of 72 and was able to perform unhindered her daily life activities” now reads “At 4 years postoperatively, the radiographs confirmed complete graft consolidation (Fig. 7), and this finding was verified with CT scanning. Clinically, the neurologic symptoms decreased in the meantime, and there was significant reduction of painful symptoms over the midclavicle. However, the symptoms over the clavicle recurred with pain and intermediate neurological symptoms. The patient subsequently underwent reoperations at the fibular donor site at another institution but continued to have persistent symptoms and a disappointing result.” On page 4, the last sentence of the fourth paragraph of the Discussion section now reads “In contrast to our case, no major persistent symptoms and complications at the free fibula extraction site have been reported in the literature, to our knowledge.” In the seventh paragraph of the Discussion, the third sentence now reads: “As the functional final result was not satisfactory, it is questionable if additional surgical steps, which could have increased the complexity of the procedure and the risk of complications, would have resulted in a more favorable clinical outcome.” In the eighth paragraph of the Discussion, the sentence that had read “However, we do believe that partial or complete resection of the clavicle alters significantly the biomechanics of the shoulder” now reads “However, it is questionable if partial or complete resection of the clavicle alters significantly the biomechanics of the shoulder. The senior author performed this same procedure in a second patient, who also had complete consolidation. The clinical outcome for that shoulder was better than the outcome reported here, but the patient had substantial donor-site morbidity.” In the last paragraph of the Discussion, the sentence that had read “In addition, biplanar stabilization of the AC joint can restore normal radiographic parameters and, thus, may affect shoulder biomechanics favorably” now reads “In addition, biplanar stabilization of the AC joint can restore normal radiographic parameters and, thus, may affect shoulder biomechanics favorably, but with the potential for persistent clinical symptoms and donor-site morbidity.”

An erratum has been published: JBJS Case Connect. 2020 May 21;10(2):e0330ER.

Case:

A 50-year-old female patient presented with significant (40%) bone loss of the lateral clavicle extending to the acromioclavicular (AC) joint, as a result of multiple, failed revision surgeries following a fracture-dislocation. She was treated with a free vascularized fibular graft and biplanar stabilization of the AC joint. At 4 years of follow-up, the patient had consolidation of the transferred fibula and experienced in the meantime reduction of painful symptoms. However, the patient subsequently had symptoms over the clavicle and donor-site morbidity in the leg, resulting in multiple reoperations.

Conclusions:

Reconstruction of large, lateral clavicle defects with a free vascularized fibular graft and biplanar stabilization of the AC joint may provide only an intermediate satisfactory clinical outcome. However, over time, this outcome can worsen with the development of symptoms over the clavicle as well as donor-site morbidity.