# Locking Plate With or Without Cerclage Augmentation Versus Hook Plate for Neer Type II Distal Clavicle Fractures: A Single-Center Retrospective Cohort

## TL;DR

This study compares two surgical methods for treating a specific type of clavicle fracture and finds that both are effective, but one avoids complications like subacromial wear.

## Contribution

The study provides a direct comparison of clinical outcomes between hook plates and locking plates with or without cerclage for Neer type II distal clavicle fractures.

## Key findings

- Both hook plates and locking plates achieved high union rates and similar functional outcomes.
- Subacromial wear occurred in 25% of hook plate cases but not in locking plate cases.
- Locking plates may be a better first-line option when distal fragment purchase is feasible.

## Abstract

Background and Objectives: Unstable distal clavicle fractures (Neer type II) have a relatively high risk of nonunion and often require operative fixation. Hook plates are widely used, particularly when the distal fragment is small or comminuted, because they provide strong vertical stability. However, hook plates are associated with subacromial irritation, acromial wear, and the need for routine implant removal. Distal locking plates with supplementary cerclage augmentation can achieve fixation without subacromial impingement and may reduce implant-related complications. This study aimed to compare clinical and radiologic outcomes of hook plates versus locking plates with or without cerclage augmentation for Neer type II distal clavicle fractures. Materials and Methods: In this single-center retrospective cohort, adult patients with Neer type II distal clavicle fractures who underwent open reduction and internal fixation between March 2021 and August 2022, with ≥6 months of follow-up, were reviewed. Patients were allocated into two groups according to implant: hook plate (Group 1, n = 16) and distal locking plate with or without cerclage augmentation (Group 2, n = 26). Primary outcomes were complication rate, radiographic union, and shoulder range of motion (ROM). Secondary outcomes included pain (PVAS) and functional scores (SANE, ASES, Constant, UCLA). Results: Forty-two patients were analyzed (locking n = 26, hook n = 16). Groups were comparable in age (51.3 ± 16.0 vs. 54.4 ± 17.1 years), follow-up (7.0 ± 4.0 vs. 8.4 ± 4.3 months), sex distribution, smoking status, and mechanism of injury. Radiographic union was achieved in 24/26 (92.3%) patients in the locking group and 14/16 (87.5%) in the hook group; two cases of nonunion or reduction failure occurred in each group (p = 0.612). Final patient-reported outcomes and ROM were similar between groups (e.g., ASES 68.2 ± 15.5 vs. 64.4 ± 18.3, Constant 57.3 ± 9.5 vs. 44.9 ± 20.5; all p > 0.05). Forward flexion tended to be higher in the locking group (138.9 ± 28.0° vs. 113.3 ± 36.7°, p = 0.182), although without statistical significance. No deep infection, peri-implant fracture, or hardware failure requiring unplanned revision was observed. Subacromial wear was identified in four patients (25%) in the hook plate group, whereas no such change was observed in the locking group. Conclusions: Both hook plates and distal locking plates (±cerclage) provided high union rates and satisfactory functional outcomes for Neer type II distal clavicle fractures. However, hook plates were associated with subacromial wear, whereas locking plate constructs avoided subacromial complications. When distal fragment purchase is feasible—or can be supplemented with cerclage augmentation—locking plate fixation represents a reliable first-line option, with hook plates reserved for cases with minimal distal bone stock or complex comminution.