Das Akromioklavikulargelenk

Acute or chronic instability and osteoarthritis of the acromioclavicular (ac) joint may cause significant impairment of the shoulder. In this continuing education report, the pathomorphology of acute ac dislocations is described based on the Rockwood classification. Decision making on conservative or surgical treatment is discussed. Surgical techniques are presented as acromioclavicular or coracoclavicular procedures. Persistent complaints may warrant additional surgical therapy after conservative treatment as well as after primary surgical treatment. In these cases, residual instability must be addressed. A modified Weaver-Dunn procedure is presented in detail. In any patient with shoulder pain, osteoarthritis of the ac joint has to be taken into consideration. Resection of the lateral clavicle has proved to be effective in these patients.     

Verletzungen und Erkrankungen des Akromioklavikulargelenkes

Osteoarthritis or instability of the acromioclavicular (AC) joint may cause significant impairment or pain in the shoulder. If symptoms of osteoarthritis persist despite conservative treatment, distal clavicular resection is usually curative. Injuries and instability are classified according to Rockwood. Treatment of mild instability due to trauma is nonoperative. An underestimated acute injury to the AC joint may result in chronic instability. Different techniques are presented for operative treatment of significant acute or chronic instability. Arthroscopic methods are now available for treating both acute and chronic instability.     

肩锁关节损伤合并盂肱关节周围组织损伤的调查

目的了解肩锁关节损伤合并盂肱关节周围组织损伤的情况及预后,分析讨论出现各种合并症的原因。 方法2015年1月至2018年8月收集了共52例肩锁关节损伤患者,分别记录肩锁关节损伤Rockwood分型,受伤机制,术前和术后12个月视觉模拟评分（visual analogue scale,VAS）,术后2个月、6个月、12个月Constant评分。 结果52例患者中,合并损伤占总数32.69%,其中11例患者进行了额外的手术治疗。术前、术后VAS评分比较差异无统计学意义（P>0.05）。盂肱关节合并伤手术治疗的患者,术后12个月随访,Constant评分没有明显好于未额外手术治疗的合并症患者（P>0.05）。 结论治疗肩锁关节的同时,仔细查验是否存在合并伤,并及时针对合并伤进行手术治疗,对肩关节功能恢复具有重要意义。     

Clinical and radiologic outcomes of surgical and conservative treatment of type III acromioclavicular joint injury

The management of acute acromioclavicular joint dislocations is controversial. The purpose of this study was to compare the incidence of posttraumatic anatomic alterations after surgical or conservative treatment of type III injuries and to analyze their effect on the outcome. Forty-three patients were evaluated retrospectively, clinically and radiographically, at a 12-month minimum follow-up. Thirty-two were treated surgically, using the Phemister technique, and 11 had conservative treatment. A comparison of the overall clinical results in both groups showed no statistically significant differences. The acromioclavicular joint was anatomically reduced in only half of the surgical patients. Those shoulders treated surgically showed a significantly higher incidence of osteoarthritis and coracoclavicular ligament ossification. Differences in clavicular deformity or osteolysis were not significant. None of these abnormalities had any influence on the clinical result. Because operative and conservative treatments achieve equally good clinical results and surgery carries a higher risk of osteoarthritis, we recommend managing this injury conservatively.     

保守治疗与锁骨钩钢板内固定手术治疗Rockwood Ⅲ型肩锁关节脱位的中长期疗效对比研究

目的通过对比评估分析保守治疗与锁骨钩钢板内固定手术治疗Rockwood Ⅲ型肩锁关节脱位的中长期临床疗效,为临床上该类型肩锁关节脱位的治疗方式的选择提供依据。 方法回顾性分析自2015年9月至2016年9月在中山市中医院关节科诊治为Roockwood Ⅲ型肩锁关节脱位的患者,入选72例,成功随访47例,采用锁骨钩钢板内固定治疗（钩钢板组）23例、采用保守治疗方法（保守治疗组）24例。随访观察比较两组术后（损伤后）1年、3年、5年视觉模拟评分法（visual analogu scale,VAS）、肩关节功能评分以及并发症发生率。 结果术后1年随访锁骨钩钢板组VAS评分稍优于保守治疗组,但两组差异无统计学意义（P>0.05）;而术后3年以及5年锁骨钩钢板组VAS评分均明显优于保守治疗组,且差异具有统计学意义（P<0.05）。术后1年、3年以及5年随访锁骨钩钢板组肩关节功能评分均明显优于保守治疗组,且差异具有统计学意义（P<0.05）;锁骨钩钢板组并发症发生率明显低于保守治疗组,且差异具有统计学意义（P<0.05）。 结论采用锁骨钩钢板内固定手术治疗Rockwood Ⅲ型肩锁关节脱位,治疗效果较好,是治疗肩锁关节Rockwood Ⅲ型肩锁关节脱位较好的方法。     

Erkrankungen des Schultereckgelenks

The acromioclavicular joint together with the sternoclavicular joint represents the only articulation between the shoulder girdle, the upper extremities and the trunk. The high load on the relative small joint surface results in a high risk for degenerative changes. The most common pathology is therefore osteoarthritis. In addition, joint instability and many inflammatory processes can occur, especially rheumatoid type pathologies and metabolic disorders. Acromioclavicular cysts represent a clinically evident disease, which are frequently associated with an underlying cuff tear arthropathy. A thorough clinical examination supported by appropriate imaging allows a rapid and reliable diagnosis. Conservative therapy is usually symptom related. Surgical procedures after failed conservative therapy must be specific for the pathology in question and are successful in most cases.     

肩关节创伤的治疗进展

肩关节结构复杂，其创伤后的治疗应根据不同的损伤类型与损伤部位正确进行选择。对移位不明显的肩部稳定性骨折(包括肱骨近端骨折、锁骨骨折和肩胛骨骨折等)、新鲜的肩肱关节脱位及损伤不严重的肩锁关节脱位，多采取保守治疗；对移位明显的不稳定性肩部骨折、复发性肩肱关节脱位、重度肩锁关节脱位、合并骨折的关节脱位及肩袖撕裂等，通常需要进行手术治疗。但无论是保守治疗还是手术治疗，均应进行早期系统的功能康复训练，才能有效恢复肩关节的功能。     

Akute Sprengung des Akromioklavikulargelenks

Dislocation of the acromioclavicular joint (AC joint) is a typical sports injury with rupture of the acromioclavicular and coracoclavicular ligaments which may result in a vertical and horizontal instability of the lateral clavicle. Stress X-rays may be of help for the diagnosis of vertical instability and for the diagnostics axial or Alexander views should be made. In the future magnetic resonance imaging (MRI) will play a significant role for the diagnostics of AC joint injuries. With this method injuries of ligaments, fascia and the glenohumeral joint can be diagnosed. There is controversy regarding the therapy of AC joint injuries. For slight injuries a conservative treatment is recommended, for medium degree instability there is too little evidence in the literature to give a clear recommendation whether conservative or operative treatment is superior and for severe instability an operative treatment is recommended. For operative treatment several techniques have been described. Some techniques have a high complication rate and implant removal is also disadvantageous. These disadvantages led to the development of minimally invasive or arthroscopic techniques. The first clinical results of these new techniques are encouraging.     

Aktuelle operative Therapiestrategien bei chronischer Akromioklavikularsgelenkinstabilität

Chronic instability of the acromioclavicular joint (AC joint) results if the initial acromioclavicular joint luxation has been missed or if the rehabilitative or surgical treatment was not successful. Late repairs after a traumatic luxation are difficult to deal with because the biological healing response for reconstitution of the ligaments seems to be compromised. A meticulous diagnostic examination should be performed paying special attention to the character and direction of instability (static versus dynamic and vertical versus horizontal). For this purpose a specified classification system should be used (Hedtmann and Heers). A new surgical technique for stabilization of chronic AC joint instability has been established and biomechanically evaluated. The technique includes an augmented modified coracoacromial ligament (only the medial half of the ligament) transfer supplemented by coracoclavicular polyester augmentation. In an in vitro model the technique was shown to restore anterior and superior translation of the intact AC joint. An increase of translation compared to the level of the intact joint was statistically significant only for the posterior direction (127%, 3.8 mm intact versus 4.6 mm following reconstruction; p<0.05). Therefore, for further improvement of the technique some form of acromioclavicular ligament reconstruction (posterosuperior) could be profitable. In conclusion the presented surgical technique (augmented CA ligament transfer) reveals promising biomechanical results in an in vitro model and may serve as an alternative to current coracoclavicular ligament reconstruction techniques using autologous tendon grafts.     

Complete dislocation of the acromioclavicular joint: operative versus conservative treatment

Abstract The preferred treatment for complete acromioclavicular separation is still controversial. The purpose of this study was to compare conservative and operative treatment on the basis of a long follow- up period, including subjective and objective clinical assessments as well as radiological evaluation. Forty-two patients with complete acromioclavicular dislocation treated operatively and 38 patients treated conservatively were examined at a mean follow-up of 6.3 years (SD=2.5). Assessment included the UCLA and the Constant-Murley scores as well as evaluation of pain, function and satisfaction. Shoulder strength was measured objectively using a cable tensiometer in four planes. The operative technique was suturing of the torn ligaments and stabilization of the acromioclavicular joint using resorbable coracoclavicular PDS banding. In conservative treatment, early physiotherapy accepting the deformity was performed in most patients. Clinical results according to the UCLA and Constant-Murley Scores as well as evaluation of pain, function and strength were similar in both groups. Three months postoperatively, the conservatively treated patients had less pain, a better range of motion and a significantly earlier return to work. Post-traumatic osteoarthritis developed only in those patients whose acromioclavicular joint healed in partial dislocation. The persisting deformity, which must be expected in conservative treatment, did not affect the patient’s outcome regarding pain or function and especially not regarding shoulder strength. With respect to the time for recovery, conservative treatment is superior to operative management. Therefore, most patients can be treated conservatively, even those patients who are heavy overhead workers or overhead athletes.     

Stabilization of the Dislocated Acromioclavicular Joint with Ligament Suture and Balser Hook Plate

Objective Reduction of dislocation and reconstruction of acromioclavicular joint by suturing the torn capsuloligamentous structures, temporary fixation with a Balser plate. Goal: restitution of form and function of shoulder girdle. Indications Primary acromioclavicular dislocation of Tossy type III or Rockwood type III in physically active patients. Acromioclavicular dislocations with additional muscle injuries of Rockwood type IV-VI. Remote painful dislocations without osteoarthritis. Here, consider patient's physical and occupational requirements. Lateral clavicle fractures with damage to clavicular ligaments. Contraindications Poor local skin condition or wounds. Symptomatic, moderate or severe osteoarthritis of acromioclavicular joint. Elevated surgical risk, poor health. Patient not agreeing to surgery. Cosmetic objections. Surgical Technique Anterior saber cut incision medial to acromioclavicular joint. Notching of insertion of deltoid muscle to expose the acromioclavicular ligaments. Placement of U-sutures in these ligaments. Refixation of intraarticular disk to clavicle with sutures. Selection of plate and subacromial insertion of its hook in close bony contact posterior to acromioclavicular joint. Radiographic control of hook and plate and of acromioclavicular joint. Plate fixation with cortex screws. Tying of the ligament sutures already in situ. Suture of joint capsule and of concomitant soft tissue disruptions. Drain. Wound closure. Results In a prospective study, 57/68 patients (62 men, six women, average age 40.3 [19-84] years) operated between 9/94 and 12/97 could be followed up clinically and sonographically after an average of 24.6 (12-49) months. Implant removal after 12 weeks. A full, painless shoulder mobility was seen in 50 patients. Sonography comparing both shoulders showed an average cranial clavicular subluxation of 0.3 mm and under a 10-kg load of 0.6 mm. Limitation of sports was reported seven times. A good to excellent result was obtained in 50 patients.     

RockwoodⅢ型肩锁关节脱位保守治疗与自体腓骨长肌腱重建喙锁韧带治疗的疗效对比研究

目的比较保守治疗与自体腓骨长肌腱前侧半（anterior half of the peroneus longus tendon, AHPLT）重建喙锁韧带治疗Rockwood Ⅲ型肩锁关节脱位的疗效。 方法自2013年6月至2016年3月共收治36例Rockwood Ⅲ型肩锁关节脱位患者。根据治疗方式不同将患者分为重建喙锁韧带组（利用自体AHPLT重建技术治疗）15例和保守治疗组21例。记录术前及术后（或保守治疗后）1、3、6、12个月的肩关节Constant、Quick DASH、VAS评分综合评估患者肩关节功能情况,并通过影像学分析复位是否丢失。 结果重建喙锁韧带组和保守组在随访1年时,患侧Constant评分分别为95.27分和97.02分,均较术前或保守治疗前Constant评分49.8分和51.8分显著提高,差异有统计学意义（P<0.05）,重建组和保守组间Constant评分差异无统计学意义（P>0.05）。一年时Quick DASH评分重建组和保守组分别为6分和2.38分,均较术前或保守治疗前23.8分和16.15分显著降低（P<0.05）,重建组和保守组间Quick DASH评分差异无统计学意义（P>0.05）。一年时VAS评分重建组和保守组分别为0.33分和0.10分,均较术前或保守治疗前4.73分和4.38分显著降低（P<0.05）,重建组和保守组间VAS评分无统计学意义（P>0.05）。1个月时,重建组Constant评分43.4分,Quick DASH评分58分,VAS评分4.27分,疗效均较保守组Constant评分65.17分,Quick DASH评分36.19分,VAS评分2.48分差（P<0.05）。3个月时重建组与保守组Constant评分无明显差异,但保守组Quick DASH评分与VAS评分较重建组好（P<0.05）。6个月时,两组间Constant评分和Quick DASH评分差异无统计学意义（P>0.05）,而VAS评分保守组较重建组更低,差异有统计学意义（P<0.05）。影像学检查提示随访1年时,重建组15例患者中有3例发生复位丢失（20%）,保守组21例中发生复位丢失的有5例（23.81%）。重建组患者均无感染,锁骨、喙突骨折等并发症发生。 结论对于Rockwood Ⅲ型肩锁脱位患者,采用重建喙锁韧带治疗或者保守治疗均能达到较好的临床效果,在早期,采用保守治疗的患者其功能和疼痛优于重建韧带治疗的患者。     

A case of acromioclavicular dislocation without coracoclavicular ligament rupture accompanied by coracoid process fracture

Acromioclavicular joint dislocation with intact coracoclavicular ligaments accompanied by fracture of the coracoid process is a rare injury. The patients are treated with conservative and/or surgical methods. A 30-year-old male patient developed type 3 acromioclavicular dislocation and coracoid process fracture due to a fall in the right shoulder. Both injuries were treated surgically. Following open reduction, the acromioclavicular joint was fixed with a Knowles pin, and the coracoid process was fixed with a 4.0-mm malleolar screw. Active-assisted rehabilitation of the shoulder was initiated a week after surgery. The patient returned to office work with a long arm splint at three weeks. Pain-free, active, and complete shoulder movements were seen in the fifth week. The Knowles pin in the acromioclavicular joint was removed under local anesthesia seven months postoperatively. A year after surgery, he resumed full shoulder functions without pain and there were no signs of complications such as heterotopic ossification.     

关节镜下Twin Tail TightRope带袢钛板Y型固定治疗急性RockwoodⅢb型以上肩锁关节脱位的早期疗效

目的评价Twin Tail TightRope带袢钛板Y型固定术治疗急性肩锁关节脱位的早期临床疗效。 方法回顾性分析2015年6月至2017年6月昆明市第一人民医院采用Twin Tail TightRope带袢钛板内固定系统在关节镜下行Y型固定治疗急性肩锁关节脱位患者共16例。采用视觉模拟评分法（visual analogue scale，VAS）及Constant-Murley评分评估手术效果。 结果所有患者获得随访，随访时间3~12个月，平均（6.48±1.51）个月。术后无血管、神经损伤及切口感染，末次随访时均未发生复位丢失、锁骨应力性骨折、喙突切割等并发症。末次随访时VAS评分（0.36±0.04）分较术前（7.46±1.24）分降低，Constant-Murley评分（90.07±3.13）分较术前（46.13±3.25）分提高。 结论采用Twin Tail TightRope带袢钛板Y型固定术治疗急性肩锁关节脱位可有效解决术后水平、前后方向不稳定问题，此技术具有较低的锁骨、喙突骨折发生率，关节镜下操作可以减少手术损伤、提高精准度。     

The effects of hook plates on the subacromial space--a clinical and MRT study

AIM: The analysis of middle- and long-term results after treatment of acromioclavicular joint injuries with a hook plate as a temporary implant and a comparison of the results with those described in literature have been made. METHOD: In a retrospective study we were able to conduct follow-up examinations on 28 out of 39 Tossy III patients (72 %) who received surgical treatment using a hook plate according to Dreithaler. Examinations took place on average 3.0 (1.2-5.6) years after surgery. A special focus of attention was the effect of the hook plate on the subacromial space. Accordingly, physical examination was supplemented by sonography of the shoulder as well as comparative bilateral shoulder MRI. RESULTS: 86 % of our patients expressed satisfaction with the functional outcome of surgery as opposed to 54 % concerning its cosmetic result. In shoulder sonography no patient turned out to have suffered a higher grade rotator cuff lesion, whereas age-related degenerative alterations were found in 46 % of the patients. Instability under load was found in 7 patients (25 %). Among these were 3 with severe instability (11 %). 2 patients (7 %) were found to have a permanent subluxation of the acromioclavicular joint with partial range of motion impairment. All scores monitored (DASH, Taft, Constant-Murley) on average returned good to excellent results. MRI scans displayed no case of higher grade rotator cuff lesion. In accordance with the findings of ultrasound imaging a higher incidence of extraarticular ossification was found as well as, in some cases, arthrosis of the acromioclavicular joint. CONCLUSION: In our opinion, the hook plate designed by Dreithaler is easy to handle and serves as a qualified implant for temporary stabilisation of the acromioclavicular joint with middle- and long-term good to excellent results.     

Ligament Injury, Reconstruction and Osteoarthritis

PURPOSE OF REVIEW: The recent literature on the factors that initiate and accelerate the progression of osteoarthritis following ligament injuries and their treatment is reviewed. RECENT FINDINGS: The ligament-injured joint is at high risk for osteoarthritis. Current conservative (e.g. rehabilitation) and surgical (e.g. reconstruction) treatment options appear not to reduce osteoarthritis following ligament injury. The extent of osteoarthritis does not appear dependent on which joint is affected, or the presence of damage to other tissues within the joint. Mechanical instability is the likely initiator of osteoarthritis in the ligament-injured patient. SUMMARY: The mechanism osteoarthritis begins with the injury rendering the joint unstable. The instability increases the sliding between the joint surfaces and reduces the efficiency of the muscles, factors that alter joint contact mechanics. The load distribution in the cartilage and underlying bone is disrupted, causing wear and increasing shear, which eventually leads to the osteochondral degeneration. The catalyst to the mechanical process is the inflammation response induced by the injury and sustained during healing. In contrast, the inflammation could be responsible for onset, while the mechanical factors accelerate progression. The mechanisms leading to osteoarthritis following ligament injury have not been fully established. A better understanding of these mechanisms should lead to alternative surgical, drug, and tissue-engineering treatment options, which could eliminate osteoarthritis in these patients. Progress is being made on all fronts. Considering that osteoarthritis is likely to occur despite current treatment options, the best solution may be prevention.     

Resection of the acromial end of clavicula in acromioclavicular joint arthrosis

Arthroses of the acromioclavicular joint mainly occur after trauma and may be the cause of pain in the shoulder region which is difficult to treat. Other possible causes are metastases, hyperparathyroidism, tuberculosis and osteolysis whose pathogenetic mechanism is still unknown. If all conservative treatment methods have been tried without success, lateral resection of the clavicula, first described in 1941 by Gurd and Mumford, is the method of choice. Some of the results obtained by the present authors with 15 patients (of whom 11 were followed up) are presented and compared with those obtained by other authors. Since the results are altogether very good, this operation, which is technically simple to perform, is recommended for arthroses of the acromioclavicular joint of any etiology. In cases with Tossy III ruptures of the joint the procedure described by Weaver and Dunn can be performed in addition.     

Painful conditions of the acromioclavicular joint.

The acromioclavicular (AC) joint may be affected by a number of pathologic processes, most commonly osteoarthritis, posttraumatic arthritis, and distal clavicle osteolysis. The correct diagnosis of a problem can usually be deduced from a thorough history, physical examination, and radiologic evaluation. Asymptomatic AC joint degeneration is frequent and does not always correlate with the presence of symptoms. Selective lidocaine injection enhances diagnostic accuracy and may correlate with surgical outcome. Nonoperative treatment is helpful for most patients, although those with osteolysis may have to modify their activities. In appropriately selected patients, open or arthroscopic distal clavicle resection is necessary to relieve symptoms. Recent biomechanical and clinical data emphasize the importance of capsular preservation and minimization of bone resection; however, the optimal amount of distal clavicle resection remains elusive. Patients with AC joint instability have poor results after distal clavicle resection.     

High patient satisfaction after arthroscopic subacromial decompression for shoulder impingement: a prospective study of 50 patients

BACKGROUND: Arthroscopic subacromial decompression (ASD) for shoulder impingement has gained popularity. We evaluated the result of this common procedure prospectively, from a patient perspective. METHOD: We used the Disability of the Arm, Shoulder and Hand questionnaire (DASH) and the Visual Analogue Scale (VAS) to evaluate 50 patients with a mean age of 49 (27-72) years. All patients had undergone 6 months of failed nonoperative treatment prior to surgery. Exclusion criteria were total rotator cuff rupture, shoulder instability, clinically verified acromioclavicular joint osteoarthritis, calcifying tendonitis or neurological symptoms. All the decompressions were done by experienced shoulder arthroscopists. RESULTS: A significant improvement in both the median DASH score and the VAS had occurred 6 months after surgery. INTERPRETATION: ASD for impingement in properly selected patients performed by experienced surgeons gives a high degree of patient satisfaction 6 months after surgery.     

Die Stabilisierung des luxierten Schultereckgelenks mit Bandnaht und Balser-Platte

Objective Reduction of dislocation and reconstruction of acromioclavicular joint by suturing the torn capsuloligamentous structures, temporary fixation with a Balser plate. Goal: restitution of form and function of shoulder girdle. Indications Primary acromioclavicular dislocation of Tossy type III or Rockwood type III in physically active patients. Acromioclavicular dislocations with additional muscle injuries of Rockwood type IV–VI. Remote painful dislocations without osteoarthritis. Here, consider patient's physical and occupational requirements. Lateral clavicle fractures with damage to clavicular ligaments. Contraindications Poor local skin condition or wounds. Symptomatic, moderate or severe osteoarthritis of acromioclavicular joint. Elevated surgical risk, poor health. Patient not agreeing to surgery. Cosmetic objections. Sugical Technique Anterior saber cut incision medial to acromioclavicular joint. Notching of insertion of deltoid muscle to expose the acromioclavicular ligaments. Placements of U-sutures in these ligaments. Refixation of intraarticular disk to clavicle with sutures. Selection of plate and subacromial insertion of its hook in close bony contact posterior to acromioclavicular joint. Radiographic control of hook and plate and of acromioclavicular joint. Plate fixation with cortex screws. Tying of the ligament sutures already in situ. Suture of joint capsule and of concomitant soft tissue disruptions. Drain. Wound closure. Results In a prospective study, 57/68 patients (62 men, six women, average age 40.3 [19–84] years) operated between 9/94 and 12/97 could be followed up clinically and sonographically after an average of 24.6 (12–49) months. Implant removal after 12 weeks. A full, painless shoulder mobility was seen in 50 patients. Sonography comparing both shoulders showed an average cranial clavicular subluxation of 0.3 mm and under a 10-kg load of 0.6 mm. Limitation of sports was reported seven times. A good to excellent result was obtained in 50 patients.