Minimally invasive plate osteosynthesis for displaced midshaft clavicle fractures: An indirect reduction using joystick technique

Published:September 29, 2022DOI:



      A minimally invasive plate osteosynthesis (MIPO) technique has become increasingly popular in long bone fracture fixation as it could eliminate postoperative complications. However, the most challenging aspect of employing the MIPO for midshaft clavicle fractures among general orthopedic surgeons is the technically demanding that indirect reduction is typically a closed maneuver.


      We present a consecutive series of patients with displaced midshaft clavicle fractures undergoing clavicular fixation using the MIPO technique between January 2017 and October 2019. The joystick technique was used to obtain anatomical reduction. Clinical outcomes were assessed using the Constant-Murley and the American shoulder and elbow surgeons shoulder scores.


      Thirty patients with a mean age of 42.44 years were included. The functional shoulder scores showed no disabilities compared with those of a healthy population. No major complications requiring re-operation were noted, and all fractures were completely healed with an average time of 12.53 weeks.


      This study demonstrated that facilitating the MIPO for midshaft clavicle fractures using simple operative devices and techniques was possible. The joystick technique with the use of an external fixator for temporary stabilization is a safe and effective method that can be added to achieve anatomical alignment with the fracture site unexposed. This technique could be performed either in a fresh fracture or a delayed case with failed conservative treatment.



      MIPO (Minimally Invasive Plate Osteosynthesis)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Orthopaedic Science
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Neer 2nd, C.S.
        Nonunion of the clavicle.
        J Am Med Assoc. 1960 Mar 5; 172: 1006-1011
        • Rowe C.R.
        An atlas of anatomy and treatment of midclavicular fractures.
        Clin Orthop Relat Res. 1968 May-Jun; 58: 29-42
        • Canadian Orthopaedic Trauma Society
        Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial.
        J Bone Joint Surg Am. 2007 Jan; 89: 1-10
        • Zlowodzki M.
        • Zelle B.A.
        • Cole P.A.
        • Jeray K.
        • McKee M.D.
        Evidence-based orthopaedic trauma working group. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the evidence-based orthopaedic trauma working group.
        J Orthop Trauma. 2005 Aug; 19: 504-507
        • Amer K.
        • Smith B.
        • Thomson J.E.
        • Congiusta D.
        • Reilly M.C.
        • Sirkin M.S.
        • et al.
        Operative versus nonoperative outcomes of middle-third clavicle fractures: a systematic review and meta-analysis.
        J Orthop Trauma. 2020 Jan; 34: e6-e13
        • Quigley T.B.
        The management of simple fracture of the clavicle in adults.
        N Engl J Med. 1950 Aug 24; 243: 286-290
        • Jiang H.
        • Qu W.
        Operative treatment of clavicle midshaft fractures using a locking compression plate: comparison between mini-invasive plate osteosynthesis (MIPPO) technique and conventional open reduction.
        Orthop Traumatol Surg Res. 2012 Oct; 98: 666-671
        • Wijdicks F.J.
        • Van der Meijden O.A.
        • Millett P.J.
        • Verleisdonk E.J.
        • Houwert R.M.
        Systematic review of the complications of plate fixation of clavicle fractures.
        Arch Orthop Trauma Surg. 2012 May; 132: 617-625
        • Toogood P.
        • Huang A.
        • Siebuhr K.
        • Miclau T.
        Minimally invasive plate osteosynthesis versus conventional open insertion techniques for osteosynthesis.
        Injury. 2018 Jun; 49: S19-S23
        • Sohn H.S.
        • Kim B.Y.
        • Shin S.J.
        A surgical technique for minimally invasive plate osteosynthesis of clavicular midshaft fractures.
        J Orthop Trauma. 2013 Apr; 27: e92-e96
        • Sohn H.S.
        • Shin S.J.
        • Kim B.Y.
        Minimally invasive plate osteosynthesis using anterior-inferior plating of clavicular midshaft fractures.
        Arch Orthop Trauma Surg. 2012 Feb; 132: 239-244
        • Jeong H.S.
        • Park K.J.
        • Kil K.M.
        • Chong S.
        • Eun H.J.
        • Lee T.S.
        • et al.
        Minimally invasive plate osteosynthesis using 3D printing for shaft fractures of clavicles: technical note.
        Arch Orthop Trauma Surg. 2014 Nov; 134: 1551-1555
        • Lee H.J.
        • Oh C.W.
        • Oh J.K.
        • Yoon J.P.
        • Kim J.W.
        • Na S.B.
        • et al.
        Percutaneous plating for comminuted midshaft fractures of the clavicle: a surgical technique to aid the reduction with nail assistance.
        Injury. 2013 Apr; 44: 465-470
        • Kundangar R.S.
        • Mohanty S.P.
        • Bhat N.S.
        Minimally invasive plate osteosynthesis (MIPO) in AO/OTA type B displaced clavicle fractures.
        Musculoskelet Surg. 2019 Aug; 103: 191-197
        • Zhang T.
        • Chen W.
        • Sun J.
        • Zhang Q.
        • Zhang Y.
        Minimally invasive plate osteosynthesis technique for displaced midshaft clavicular fracture using the clavicle reductor.
        Int Orthop. 2017 Aug; 41: 1679-1683
        • Constant C.R.
        • Murley A.H.
        A clinical method of functional assessment of the shoulder.
        Clin Orthop Relat Res. 1987 Jan; 214: 160-164
        • Michener L.A.
        • McClure P.W.
        • Sennett B.J.
        American shoulder and elbow surgeons standardized shoulder assessment form, patient self-report section: reliability, validity, and responsiveness.
        J Shoulder Elbow Surg. 2002 Nov-Dec; 11: 587-594
        • Tan S.L.
        • Balogh Z.J.
        Indications and limitations of locked plating.
        Injury. 2009 Jul; 40: 683-691
        • Chechik O.
        • Batash R.
        • Goldstein Y.
        • Snir N.
        • Amar E.
        • Drexler M.
        • et al.
        Surgical approach for open reduction and internal fixation of clavicle fractures: a comparison of vertical and horizontal incisions.
        Int Orthop. 2019 Aug; 43: 1977-1982
        • Schemitsch L.A.
        • Schemitsch E.H.
        • Kuzyk P.
        • McKee M.D.
        Prognostic factors for reoperation after plate fixation of the midshaft clavicle.
        J Orthop Trauma. 2015 Dec; 29: 533-537
        • Woltz S.
        • Duijff J.W.
        • Hoogendoorn J.M.
        • Rhemrev S.J.
        • Breederveld R.S.
        • Schipper I.B.
        • et al.
        Reconstruction plates for midshaft clavicular fractures: a retrospective cohort study.
        Orthop Traumatol Surg Res. 2016 Feb; 102: 25-29
        • Chiu Y.C.
        • Huang K.C.
        • Shih C.M.
        • Lee K.T.
        • Chen K.H.
        • Hsu C.E.
        Comparison of implant failure rates of different plates for midshaft clavicular fractures based on fracture classifications.
        J Orthop Surg Res. 2019 Jul 16; 14: 220
        • Eden L.
        • Doht S.
        • Frey S.P.
        • Ziegler D.
        • Stoyhe J.
        • Fehske K.
        • et al.
        Biomechanical comparison of the Locking Compression superior anterior clavicle plate with seven and ten hole reconstruction plates in midshaft clavicle fracture stabilisation.
        Int Orthop. 2012 Dec; 36: 2537-2543
        • Iannotti M.R.
        • Crosby L.A.
        • Stafford P.
        • Grayson G.
        • Goulet R.
        Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study.
        J Shoulder Elbow Surg. 2002 Sep-Oct; 11: 457-462