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Original Article
Treatment of distal-third clavicular fractures (Neer type II-b) with a triple button device
Tratamiento de fracturas de tercio distal de clavícula (tipo ii-b de Neer) con sistema de triple botón
J.A. Cano-Martínez
Corresponding author
dockano@hotmail.com

Corresponding author.
, G. Nicolás-Serrano, J. Andrés-Grau, J. Bento-Gerard
Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Los Arcos del Mar Menor, Facultad de Medicina, Universidad de Murcia, Pozo Aledo, Murcia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent series distal-third clavicular fractures make up 21&#8211;28&#37; of all clavicular fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">1</span></a> Road or sports accidents are the most common mechanisms of trauma in young people&#44; followed by low energy falls in elderly patients&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Neer&#39;s classification<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">3</span></a> is the most frequently used and includes 3 fracture types&#46; In type I&#44; the fracture is lateral to the coracoclavicular ligaments and there is minimal displacement&#46; In type III there is an articular fracture line&#46; Both types are considered stable and are treated conservatively&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Type II injuries are unstable&#44; because the fracture is medial to the coracoclavicular ligaments and the medial fragment is drawn upwards and backwards by the effect of the trapezius&#46; In addition&#44; the distal fragment is pulled downwards by the weight of the arm and rotated by the scapula &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Neer type II is subdivided into 2 subtypes&#58; type II-a&#44; where both ligaments are joined to the distal fragment&#44; and type II-b&#44; where the trapezoid ligament remains inserted in the distal fragment&#44; the conoid ligament being torn&#44; which results in greater displacement between fragments&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Since the first clinical series&#44; the trend has been towards treating these Neer type II injuries surgically&#44; justified by the high incidence of pseudoarthrosis&#44; 22&#8211;50&#37;&#44; <a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">4&#8211;6</span></a> consolidation delays &#40;45&#8211;67&#37; take more than 3 months to heal&#41; and discomfort in the patients who are treated orthopedically&#44; with the clinical and social consequences that this involves&#44; especially for young patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The number of treatment techniques has increased considerably in recent years&#44; including arthroscopic alternatives&#44; and generally achieve satisfactory outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">9&#8211;15</span></a> The problem with most relates to the implant&#44; either because it moves&#44; causes discomfort or pain&#44; making it necessary to remove it&#44; and fails to maintain proper reduction to enable correct consolidation&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">16</span></a> Because they are rare&#44; it is difficult to obtain long series with sufficient follow-up to extract scientifically valuable data &#40;most are level IV<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">2</span></a> studies&#41; so as to be able to decide the best therapeutic option&#46; The objective of this study is to present our experience and outcomes with the coracoclavicular triple button TightRope system &#40;Twin Tail TightRope&#8482;&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0030" class="elsevierStylePara elsevierViewall">A retrospective study was performed which included Neer type II-b distal-third clavicular fractures operated using the Twin Tail TightRope&#8482; system &#40;Arthrex&#44; Naples&#44; FL&#44; U&#46;S&#46;A&#46;&#41; in our work centre from November 11 to December 2014&#44; with a minimum of one year&#39;s follow-up in order to form part of the study&#46; Patients with skeletal immaturity&#44; fractures or previous shoulder injury surgery&#44; patients with a high anaesthetic risk or those who did not want to participate in the study were excluded&#46; Of the 14 patients who met the criteria&#44; 2 were excluded&#58; one was lost to follow-up and another presented a previous fracture in the injured clavicle&#44; a total of 12 patients remained for the final study&#58; 10 males &#40;83&#46;3&#37;&#41; and 2 females &#40;16&#46;7&#37;&#41;&#46; The mean age was 32&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;51 years &#40;range&#44; 18&#8211;56&#41;&#46; The causes were 5 road traffic accidents &#40;3 car and 2 motorbike&#41;&#44; 6 were sports injuries &#40;2 cycling&#44; 2 football&#44; one rugby and one martial arts&#41; and one accidental fall&#46; The right side was injured in 7 patients &#40;58&#46;3&#37;&#41; and the left in 5 patients &#40;41&#46;7&#37;&#41;&#46; Mean follow-up was 26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;24 months &#40;range&#44; 12&#8211;48 months&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All the patients included in the study underwent a standard anteroposterior X-ray of the shoulder and projection of the clavicle with 30&#176; cephalic tilt&#44; both without load&#46; Radiological assessment was undertaken preoperatively and postoperatively&#58; every 2 weeks for the first 2 months&#44; monthly from the third to the sixth month&#44; and then annually&#46; Radiological healing was defined as the presence of bone bridging obliterating the fracture space with no significant radiolucencies around it&#46; Clinical healing was defined as the absence of spontaneous pain or pain on palpation of the fracture site&#44; and articular balance of the shoulder with no pain&#46; Similarly Constant<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">17</span></a> and DASH<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">18</span></a> scores were calculated at their very last follow-up&#46; Radiological assessment and the clinical tests were undertaken by two surgeons who were independent of the study &#40;JBG&#44; FG&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The presence of major complications was assessed&#44; such as those requiring a second unscheduled operation &#40;deep infection requiring surgical drainage&#44; implant failure&#44; need for revision due to reduction loss&#44; non-union&#41;&#44; and minor complications which did not necessitate reoperation &#40;intolerance to the material&#44; superficial infection resolved with medical treatment&#44; problems with scarring&#44; calcifications&#41;&#46; The need to remove the material was recorded independently from the rest of the complications&#46; All the patients gave their written consent&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0045" class="elsevierStylePara elsevierViewall">The patients were operated in the deckchair position&#44; with a pillow underneath the ipsilateral scapula&#46; The arm was left free so as to be able to move it during the operation&#46; The patients were given a general anaesthetic and an associated ultrasound-guided upper limb nerve block&#46; Antibiotic prophylaxis with cefazolin was administered&#46; All the operations were performed by 2 shoulder surgeons &#40;JAC&#59;GNS&#41;&#46; The triple button system was used &#40;AC Twin Tail<span class="elsevierStyleSup">&#174;</span>&#44; Arthrex&#44; Naples&#44; FL&#44; U&#46;S&#46;A&#46;&#41;&#46; This is a system designed for the treatment of acromioclavicular dislocation that comprises a button to place below the coracoid apophysis and 2 clavicular buttons intended to reproduce the disposition of the coracoclavicular ligaments&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A vertical incision is made&#44; slightly medial to the acromioclavicular joint&#44; to the coracoid apophysis&#44; about 5<span class="elsevierStyleHsp" style=""></span>cm long&#46; After opening the deltopectoral fascia the distal third of the clavicle is exposed &#40;without stripping the periosteum of the distal fragment&#41; and the upper surface of the coracoid apophysis is released by blunt dissection&#46; An orifice is made with a 4&#46;5<span class="elsevierStyleHsp" style=""></span>mm drill bit with visceral protection placed below its lower surface&#59; 2 4&#46;5<span class="elsevierStyleHsp" style=""></span>mm orifices are made in the same way in the proximal fragment of the distal clavicle &#40;in the original technique they are 4<span class="elsevierStyleHsp" style=""></span>mm&#41;&#58; the most medial orifice in the posterior clavicular third &#40;at around 40<span class="elsevierStyleHsp" style=""></span>mm from the joint&#41; and the most lateral&#44; in the anterior clavicular third &#40;at around 25<span class="elsevierStyleHsp" style=""></span>mm from the joint&#41;&#46; The device with its three buttons is introduced through these orifices&#44; with the help of specific pins&#46; The fracture is reduced indirectly&#44; pushing the proximal fragment downwards to its anatomical location by digital pressure while abducting the arm&#59; once it has been reduced in the desired place&#44; the sutures are fastened&#44; closing the fascia and the deltopectoral musculature &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a and b&#41;&#46; The skin is closed with a continuous intradermal suture&#44; which is removed after approximately 15 days&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The postoperative protocol involves immobilisation in a sling in internal rotation and abduction for one month&#44; allowing pendular movements from the first postoperative day&#46; Limited elevation and abduction movements at 90&#176; are allowed from the third week&#44; and complete articular balance from the sixth week&#46; Muscle strength potentiation is allowed from week 12&#46; Contact sport or intensive physical activity is not allowed until the sixth month&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">A descriptive analysis was made of each variable&#44; and the data shown as arithmetic mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation with the range in brackets&#46; Fisher&#39;s exact test was used to analyse the relationship between 2 categorical variables&#46; Mann&#8211;Whitney&#39;s <span class="elsevierStyleItalic">U</span> test was used to establish any differences between means of dichotomous qualitative variables&#46; Kruskal&#8211;Wallis test was used to check equality between means of non-dichotomous variables&#46; SPSS software&#44; version 19&#46;0&#44; &#40;IBM Corp&#44; Armonk&#44; NY&#44; U&#46;S&#46;A&#46;&#41; was used for the statistical analysis&#46; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered a statistically significant level&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">The mean time to clinical healing was from 10&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;1 weeks &#40;range&#44; 8&#8211;16&#41;&#44; and to radiological healing&#44; from 13&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;6 weeks &#40;range&#44; 12&#8211;20&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>a&#8211;c&#41;&#46; The mean Constant score was 95&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;2 points &#40;range&#44; 85&#8211;100&#41; and the mean DASH score&#44; 3&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;4 points &#40;range&#44; 0&#8211;12&#46;5&#41;&#46; No major complications presented&#44; such as reduction losses&#44; fractures around the implant or deep infections&#46; There were minor complications&#58; one superficial surgical wound infection which was resolved with oral antibiotics &#40;8&#46;3&#37;&#41;&#44; one patient developed a hypertrophic scar with a poor cosmetic result &#40;8&#46;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#44; another patient experienced discomfort with the clavicular buttons &#40;8&#46;3&#37;&#41;&#44; and another 2 patients showed calcifications in the coracoclavicular space on X-ray &#40;16&#46;6&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#59; <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; No patient required reoperation to remove the implant&#46; The patients resumed their usual activities prior to the injury at 15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;8 weeks &#40;range&#44; 12&#8211;20&#41; with no restrictions&#44; and returned to sport from the sixth month in all cases&#46; The mean surgery time was 53&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;6<span class="elsevierStyleHsp" style=""></span>min &#40;range&#44; 42&#8211;81&#41;&#46; There were no cases of non-union&#44; degenerative joint changes or the presence of fractures around the triple button system orifices during follow-up&#46; There was no statistically significant association between&#44; sex&#44; age&#44; injured side or causative mechanism with the clinical outcomes &#40;test score&#41;&#44; radiological outcomes &#40;clinical healing&#41; or the onset of complications&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The definitive treatment for distal-third clavicular fractures&#44; more specifically Neer type II-b fractures&#44; remains a challenge&#46; In any case&#44; due to instability and the multiple deforming forces that act on the fracture site&#44; surgical treatment is the best therapeutic option&#44;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">6&#44;19&#44;20</span></a> since rates of over 14&#37; of symptomatic pseudoarthrosis in young patients are not acceptable&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The different ways of radiographically assessing these fractures &#40;projections with or without load&#44; purely anteroposterior or with degrees of tilt&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">23</span></a> and the different clinical tests used in the different studies &#40;Constant-Murley Score<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">18</span></a>&#44; DASH<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">19</span></a>&#44; Taft Score<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">24</span></a>&#44; ASES<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">20</span></a>&#44; UCLA<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">25</span></a>&#44; Oxford<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">26</span></a> or MSRS<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">27</span></a>&#41;&#44; make comparison difficult&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Two main groups of surgical techniques are used for treatment&#58; those that attempt direct healing by rigid fixation &#40;traditional osteosynthesis&#44; with different types of plates&#41; and those that attempt indirect healing by flexible fixation &#40;different coracoclavicular fixation systems&#44; some of which can be performed arthroscopically&#41;&#46; Most of the techniques used have provided good outcomes in terms of clinical and radiological healing&#44; although to date no technique has proved superior to another&#46; The problem with these techniques is essentially down to the material &#40;intolerance&#44; movement&#44; infection&#41;&#44; inadequacy of the technique &#40;reduction loss&#41; or articular damage &#40;acromioclavicular arthrosis&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Transfixation systems<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">14&#44;28&#44;29</span></a> associated or otherwise with tension band<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">30</span></a> are problematic in that they can damage the acromioclavicular joint&#44; and can generate secondary arthrosis&#46; With all of them the material has to be removed before starting complete range of movement since&#44; as they interfere with normal scapular rotation&#44; they can fail and break&#46; Another problem with them is that the pins can migrate<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">31</span></a> &#40;80&#37; in some series&#41;&#44; they can become infected&#44; and they can prove inadequate in maintaining suitable reduction in up to 10&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">32</span></a> The coracoclavicular screw&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">33</span></a> as well as the malleolar screw&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">8</span></a> are not easy to implant&#44; it is also necessary to remove them before they can break&#46; Furthermore&#44; in small coracoids or porous bone there is a failure rate of up to 32&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">34</span></a> Amongst these systems&#44; hook plating<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">9&#44;35</span></a> is a technique that has demonstrated more consistent outcomes and has been used in a greater number of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">2</span></a> It is very useful when the distal fragment is very small and has proved more effective than treatment with Kirschner tension band wiring&#44;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">36</span></a> although it presents more complications than the use of plates together with coracoclavicular cerclage&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">16&#44;37</span></a> The problem is that it is too rigid a technique and it protrudes into subcutaneous tissue&#44; and therefore has to be removed in almost 100&#37; of cases as soon as the fracture has consolidated in order to prevent acromion osteolysis and fracture&#44; injury to the cuff or subacromial conflict&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">38</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Conventional clavicle plates&#44; distal radius plates or the recent preshaped plates have the great advantage of providing rigid fixation&#44; with screws locked to the plate of different sizes and angulations&#44; without affecting the acromioclavicular joint&#46; The main problems with them are the need for wide exposure which can devascularise the clavicle&#44; and the need to remove them due to discomfort produced by the material in between 17&#37; and 45&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">24&#44;39&#44;40</span></a> Another problem is that fractures due to weakness &#40;stress shielding&#41; in the site of the screw orifices<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">34</span></a> can occur when they are removed&#46; On other occasions&#44; the lateral fragment is so small and comminuted that an insufficient number of screws can be put into the frame &#40;at least 2 bicortical screws&#41;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">39</span></a> to ensure stability&#44; which has to be supplemented with another coracoclavicular technique&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">41</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Isolated coracoclavicular cerclages &#40;1 or 2&#41;&#44; secured to harpoon suture anchors in the coracoid or otherwise&#44; have also proved effective&#44; although they present frequent reduction losses<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">42</span></a> with the added risk of &#8220;wearing down&#8221; and causing a differed fracture to the clavicle itself in 11&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">43&#44;44</span></a> These techniques performed arthroscopically have provided satisfactory outcomes&#44; but require a high learning curve in order to perform them effectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">45&#44;46</span></a> The use of combined techniques has become more widespread<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">47&#44;48</span></a>&#58; plates with coracoclavicular cerclage using harpoon suture anchors&#44;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">16&#44;49</span></a> harpoon suture anchors for coracoclavicular suture with transarticular fixation<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">14&#44;25&#44;27</span></a> or plates with TightRope-type systems&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">1</span></a> Although the outcomes of these combinations are satisfactory&#44; they involve greater financial cost&#44; make surgery more complex as various techniques are used&#44; and they increase the risk of devascularising fragments in order to be able to implant the 2 systems correctly&#46; Robinson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">20</span></a> used a simple TightRope system &#40;double button&#41; by open surgery&#59; this shares the advantage with our technique of theoretically not having to remove the implant&#44; but had a 6&#46;25&#37; incidence of non-unions&#44; which we did not experience in our series&#46; This might be due to the fact that this system is not effective in treating more complex injuries with greater tissue damage&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The literature describes clinical healing as taking place from the sixth<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">32&#44;33&#44;37&#44;50</span></a> to the fourteenth<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">25</span></a> week if there are no complications&#44; which coincides with the data obtained in this review&#46; In our series&#44; clinical healing always preceded radiological healing &#40;around 3&#46;4 weeks&#41;&#44; as also described by Abdeldayem et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">50</span></a> since soft tissues heal before radiological changes are visible&#46; In fact&#44; as it is an anatomical and stable reduction&#44; consolidation is essentially <span class="elsevierStyleItalic">per primam</span>&#44; and therefore a large bone callous would not be expected to appear&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The triple button system&#44; initially designed to treat acute acromioclavicular dislocation and demonstrated to be effective in the laboratory&#44;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">51</span></a> recreates the anatomy of the coracoclavicular ligaments&#46; We have not found previous use of the system for this type of injury in the literature&#46; For us this system has several advantages compared to others&#44; as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mechanical&#46;</span> The orthogonal disposition of the implant in 2 planes of the space at clavicle level enables the function of the conoid ligament to be supplanted and the injured remainder of the trapezoid ligament to be supported&#44; providing more stability than the simple coracoclavicular systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">52&#44;53</span></a> This technique enables the forces of the arm and the scapula to pass from the coracoids to the medial fragment&#44; reducing the forces that act on the fracture site&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Biological&#46;</span> An indirect reduction of the fracture site is made&#44; size and lateral fragment comminution are not important&#46; The injury site is cleaned without stripping the periosteum&#44; maintaining the soft tissue insertions which might be essential for the injury to heal and for it to consolidate earlier&#44; avoiding consolidation delays and pseudoarthrosis&#59; this is an advantage compared to the use of plates&#46; Furthermore&#44; not crossing the joint prevents secondary articular damage&#44; and therefore the stiffness and capsulitis described in other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">2</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Technical&#46;</span> This technique is fast &#40;less than one hour&#39;s surgery&#41;&#44; safe &#40;everything takes place under direct vision&#41; and easy &#40;at no time does the distal fragment need to be manipulated&#44; which is often comminuted and difficult to synthesise&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;4&#41;</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Clinical&#46;</span> The clinical test scores show outcomes that are at least equal to those described after the traditional techniques &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There is less neurovascular risk than with the arthroscopic techniques and traditional coracoclavicular cerclages&#44; because the orifice in the coracoid is made under direct vision and there is no need to pass through any element medial to it&#46; We did not need to reoperate any of the patients to remove the material&#44; which reduces morbidity&#46; Despite the subcutaneous position of the clavicle&#44; the low profile of the implants means that the material implanted in it does not protrude through the skin&#44; cause discomfort or even hurt when certain movements are made&#46; Even so&#44; one patient in the series&#44; slim &#40;with little adipose panicle&#41;&#44; presented discomfort with the clavicular buttons&#44; but this did not warrant their removal&#46; All the patients were able to resume their previous activities with no restrictions&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;5&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Financial&#46;</span> As a second operation was not required&#44; we avoided the costs of further intervention&#44; associated sick leave and possible complications&#46;</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">The main radiological complication of the triple button system was the appearance of calcifications &#8211; already described in other studies with rates of 7&#8211;12&#37;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">14</span></a>&#8212;although this is not associated with poorer clinical outcomes and&#44; as in the case of acromioclavicular dislocation&#44; might be no more than the organism attempting to stabilise an injured joint&#46; The appearance of a hypertrophic scar is explained by the anatomical location of the operation&#44; because the shoulder area is more likely to develop these types of scars&#46; This results in poorer cosmetic results but not in poorer clinical outcomes&#46; We had one superficial wound infection that responded to conservative treatment&#59; this is a possibility inherent to any surgical procedure and appears in practically all the series described in the literature&#46; Our rehabilitation protocol does not differ greatly from those described in the literature&#44; it being important to find a balance between the immobilisation time &#8211; which should not be excessive so as to avoid scapular dyskinesis <a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">54</span></a>&#8212;and movement sequences once healing is underway&#46; This injury is defined as a bone fracture&#44; but is principally a ligament problem with the instability it generates&#59; therefore any system must provide sufficient rigidity without excessively damaging the tissue insertions so that the bone can consolidate correctly&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">This study has a series of limitations&#46; Firstly&#44; it is a retrospective observational study&#59; secondly&#44; it presents a low number of patients&#44; since the frequency of the injury makes long series with a minimum follow-up difficult in order to be able to compare surgical techniques with sufficient scientific evidence<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">2</span></a>&#59; thirdly&#44; the lack of a control group to compare outcomes limits the validity of the conclusions&#46; Therefore&#44; prospective and comparative studies with a greater number of cases are necessary to clarify which technique offers the best outcomes in the management of these injuries&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">The triple button system is an alternative to the more conventional methods for the treatment of Neer type II-b distal-third clavicular fractures&#46; It is reproducible and effective&#44; both clinically and radiologically&#46; Its main advantage is that a second intervention is not required to remove it&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Level of evidence</span><p id="par0150" class="elsevierStylePara elsevierViewall">Level of evidence IV&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of people and animals subjects</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that neither human nor animal testing have been carried out under this research&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have complied with their work centre protocols for the publication of patient data&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that no patients&#8217; data appear in this article&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">There was no source of funding available to undertake this study&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interests</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare in preparing and submitting this article&#46;</p></span></span>"
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    "fechaRecibido" => "2016-02-29"
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            0 => "Distal third clavicle fracture"
            1 => "Unstable distal clavicle"
            2 => "Triple button device"
            3 => "Coracoclavicular stabilisation"
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            0 => "Fractura tercio distal clav&#237;cula"
            1 => "Clav&#237;cula lateral inestable"
            2 => "Dispositivo de triple bot&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The purpose of this study is to describe the outcomes of using a triple button device for the treatment of displaced distal-third clavicle fractures &#40;Neer type II-b&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective review was conducted on a series of patients between November 2011 and December 2014&#46; Fourteen patients initially met the inclusion criteria&#44; but 2 were excluded&#44; leaving 12 patients &#40;83&#46;3&#37; male&#59; mean age 32&#46;2 years&#41; for the final analysis at a mean follow-up of 26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;24 months &#40;range&#44; 12&#8211;48&#41;&#46; Post-operative follow-up was performed at 2 weeks &#40;two first months&#41;&#44; and monthly thereafter&#44; until was achieving clinically and radiological healing&#46; The functional outcome was evaluated using the Constant score&#44; and DASH score in the last follow-up&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean Constant Score was 95&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;2 points &#40;range&#44; 85&#8211;100&#41;&#44; with a mean DASH score of 3&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;4 points &#40;range&#44; 0&#8211;12&#46;5&#41;&#46; The mean time to clinical healing was 10&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;1 weeks &#40;range&#44; 8&#8211;16&#41;&#44; and the mean time to radiological healing was 13&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;6 weeks &#40;range&#44; 12&#8211;20&#41;&#46; There were no major complications&#46; There were 5 minor complications without clinical impact&#58; 2 coracoclavicular calcifications&#44; 1 hypertrophic scar&#44; 1 patient with discomfort due to the device&#44; and 1 superficial wound infection&#46; All patients returned their previous activity&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Good clinical results can be achieved with the triple button device in unstable distal fractures of the clavicle&#44; without the need to remove the hardware&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio es describir los resultados de un dispositivo de triple bot&#243;n para el tratamiento de las fracturas desplazadas de tercio distal de clav&#237;cula &#40;tipo <span class="elsevierStyleSmallCaps">ii</span>-b de Neer&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de una serie de pacientes entre noviembre de 2011 y diciembre de 2014&#46; Catorce pacientes se ajustaron inicialmente a los criterios de inclusi&#243;n&#44; 2 de los cuales fueron excluidos&#44; dejando 12 pacientes &#40;83&#44;3&#37; varones&#59; edad media 32&#44;2 a&#241;os&#41; para el an&#225;lisis final&#46; El seguimiento medio fue de 26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;24 meses &#40;rango&#44; 12-48&#41;&#46; El seguimiento postoperatorio se realiz&#243; a las 2 semanas &#40;en los 2 primeros meses&#41; y despu&#233;s mensualmente&#44; hasta que se consigui&#243; la curaci&#243;n cl&#237;nica y radiol&#243;gica&#46; El resultado funcional se evalu&#243; mediante el test de Constant y la puntuaci&#243;n DASH en el &#250;ltimo seguimiento&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La puntuaci&#243;n media del test de Constant fue de 95&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;2 puntos &#40;rango&#44; 85-100&#41; y la del test DASH&#44; de 3&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;4 puntos &#40;rango&#58; 0-12&#44;5&#41;&#46; El tiempo medio para la curaci&#243;n cl&#237;nica fue de 10&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;1 semanas &#40;rango&#44; 8-16&#41; y para la consolidaci&#243;n radiol&#243;gica&#44; de 13&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;6 semanas &#40;rango&#44; 12-20&#41;&#46; No hubo complicaciones mayores&#46; Hubo 5 complicaciones menores sin repercusi&#243;n cl&#237;nica&#58; 2 calcificaciones coracoclaviculares&#44; una cicatriz hipertr&#243;fica&#44; un paciente con molestias sobre el dispositivo y una infecci&#243;n de la herida&#46; Todos los pacientes retomaron su actividad previa&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El dispositivo de triple bot&#243;n consigue excelentes resultados en el tratamiento de las fracturas de tercio distal de clav&#237;cula sin necesidad de retirar el material&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cano-Mart&#237;nez JA&#44; Nicol&#225;s-Serrano G&#44; Andr&#233;s-Grau J&#44; Bento-Gerard J&#46; Tratamiento de fracturas de tercio distal de clav&#237;cula &#40;tipo <span class="elsevierStyleSmallCaps">ii</span>-b de Neer&#41; con sistema de triple bot&#243;n&#46; Rev Esp Cir Ortop Traumatol&#46; 2016&#59;60&#58;378&#8211;386&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Case number 1&#46; Anteroposterior X-ray of the left clavicle showing a Neer type II-b distal clavicle fracture&#46; L&#44; left&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Case number 9&#46; &#40;A&#41; Intraoperative image showing the anatomical reduction of the fracture &#40;blue arrow&#41; and the disposition of the implant in the proximal clavicle &#40;D-CLA&#58; distal clavicle&#59; P-CLA&#58; proximal clavicle&#59; Co&#58; coracoid&#41;&#46; &#40;B&#41; Postoperative check shown in the anteroposterior projection of the shoulder&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Case number 2&#46; Anteroposterior X-ray of the clavicle in 30&#176; of cephalic tilt&#46; &#40;A&#41; Preoperative&#46; &#40;B&#41; Immediately postoperative&#46; &#40;C&#41; Radiological consolidation at 12 weeks after surgery&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Case number 8&#46; Hypertrophic scar present at 2 month follow-up&#46; We can observe the extrusion of sutures from the subcutaneous tissue in the proximal and distal part of the wound &#40;white arrows&#41;&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Case number 3&#46; Anteroposterior X-ray of the clavicle showing ossification of the coracoclavicular ligament route at 6 months after surgery &#40;white arrow&#41;&#46; R&#44; right&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mechanism&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RH&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Traffic accident &#40;car&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Traffic &#40;motorbike&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Coracoclavicular calcifications<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>discomfort with the material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sport &#40;football&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Traffic accident &#40;motorbike&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sport &#40;football&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sport &#40;martial arts&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial wound infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Traffic accident &#40;car&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertrophic scar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Traffic &#40;car&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Coracoclavicular calcifications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sport &#40;cycling&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sport &#40;rugby&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">KW&#44; Kirschner wires&#59; KWSA&#44; Kirschner wires plus harpoon suture anchor&#59; ASES&#44; <span class="elsevierStyleItalic">American Shoulder and Elbow Surgeons</span>&#59; MBT&#44; modified tension band&#59; CC&#44; coracoclavicular cerclage&#59; CS&#44; <span class="elsevierStyleItalic">Constant-Murley Score</span>&#59; DASH&#44; <span class="elsevierStyleItalic">Disabilities of the Arm&#44; Shoulder and Hand</span>&#59; DB&#44; double button&#59; RM&#44; removal of material&#59; MSRS&#44; <span class="elsevierStyleItalic">Modified Shoulder Rating Scale</span>&#59; <span class="elsevierStyleItalic">n</span>&#44; number of cases&#59; OS&#44; <span class="elsevierStyleItalic">Oxford Score</span>&#59; CP&#44; clavicle plate&#59; GP&#44; hook plate&#59; RP&#44; radius plate&#59; Fol&#44; follow-up in months&#59; TB&#44; triple button&#59; CS&#44; coracoclavicular screw&#59; UR&#44; rate of clinical-radiological union in percentage&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FOL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Choi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">25</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MBT<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CS&#58; 94&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Peri-implant fracture &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fleming et al&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OS&#58; 47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discomfort with the material &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CC&#47;KW&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100 &#40;kW&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdeldayem et al&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MSRS&#58; 18&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial infection &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beirer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CS&#58; 85&#46;6<br>DASH&#58; 7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discomfort with the material &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tambe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">35</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CS&#58; 88&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deep infection &#40;1&#41;<br>Peri-implant fracture &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Klein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CP<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ASES 77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deep infection &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Andersen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CP<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deep infection &#40;1&#41;<br>Peri-implant fracture &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kalamaras et al&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RP<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CS&#58; 96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deep infection &#40;1&#41;<br>Deficient reduction &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bezer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">KWSA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CS&#58; 96&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100 &#40;kW&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Robinson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CS&#58; 87&#46;1<br>DASH&#58; 3&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Capsulitis &#40;1&#41;<br>Pseudoarthrosis &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CS&#58; 95&#46;6<br>DASH&#58; 3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial infection &#40;1&#41;<br>Hypertrophic scars &#40;2&#41;<br>Coracoclavicular calcification &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Comparison of our review with studies published in the literature&#46;</p>"
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      ]
    ]
    "bibliografia" => array:2 [
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