关节镜辅助喙锁悬吊固定联合改良Weaver-unn手术治疗陈旧性肩锁关节脱位

目的探讨关节镜辅助喙锁悬吊固定联合改良Weaver-Dunn手术治疗陈旧性肩锁关节脱位的疗效。 方法2016年3月至2017年3月,对8例陈旧性肩锁关节脱位的患者采用关节镜下喙锁间隙悬吊固定联合改良Weaver-Dunn手术,术后随访6~18个月。测量术后即刻与末次随访时的喙锁间隙差值,评估复位丢失情况,采用疼痛视觉模拟（VAS）评分及加州大学洛杉矶分校（UCLA）评分评价患者肩关节功能。 结果术后末次随访时患者喙锁间隙与术后即刻喙锁间隙差值为（0.41±0.26）mm,VAS评分为2.88分,UCLA评分为（173.6±11.3）分,患者肩锁关节丢失率低、术后疼痛及功能均得到明显改善。 结论关节镜辅助喙锁固定联合改良Weaver-Dunn技术治疗陈旧性肩锁关节脱位有较好的疗效。     

双束Endobutton解剖重建喙锁韧带治疗肩锁关节脱位的早期随访研究

目的观察解剖重建喙锁韧带治疗Rockwood Ⅲ及以上肩锁关节脱位的临床疗效。 方法选取22例肩锁关节脱位患者,其中男15例、女7例,新鲜脱位16例,陈旧性脱位6例,Rockwood Ⅲ型7例、Ⅳ型1例、V型14例。手术方式选择为双束Endobutton解剖重建技术。分别于术后3、6和12个月行疼痛视觉模拟评分及Constant肩关节功能评分,摄双侧肩关节正位X线片,测量患侧及健侧喙锁间距。 结果此研究平均随访时间为（17.7±4.0）个月。疼痛视觉模拟评分从术前的平均5.0分下降到术后12个月的0.2分,Constant肩关节功能评分从术前的平均44.3分提高到术后12个月的93.7分。患侧喙锁间距从术前的平均21.0 mm下降到术后12个月的8.5 mm。所有病例随访过程中均无肩锁关节再脱位、锁骨喙突骨折等严重并发症发生。 结论双束Endobutton解剖重建喙锁韧带是安全可靠的新术式,其应用于Rockwood Ⅲ-V型新鲜或者陈旧性肩锁关节脱位的手术治疗取得了良好的临床效果。     

喙锁韧带重建的解剖放射学研究

目的测量不同透视体位下喙锁韧带骨道走行的放射学参数，为临床喙锁韧带重建提供解剖学依据。 方法取22具防腐处理的成人肩关节标本，解剖测量喙锁韧带两部分（斜方韧带，锥状韧带）的走行方向、止点宽度及透视体位下成角。 结果斜方韧带锁骨侧足印宽度（26.2±1.2） mm，喙突侧（22.7±1.6）mm。锥状韧带锁骨侧足印宽度（24.6±1.4）mm，喙突侧（19.2±1.6）mm。影像学测量韧带的插入角度：肩胛骨正位与锥状韧带与锁骨长轴成角（81±4）°，斜方韧带成角（67±7）°。侧位成角：斜方韧带（83±3）°，锥状韧带（70±6）°。与外科标志的毗邻关系：斜方韧带与锥状韧带足印区长轴中心点在锁骨间距（21.9±4.8）mm，在喙突侧间距（15.7±1.6）mm。 结论锥状韧带及斜方韧带止点足印宽度较为恒定，斜方韧带插入角度有变异度较大，锥状韧带较为恒定。两韧带在锁骨及喙突上间距较小。在进行肩锁关节解剖重建时，可参照其解剖学特点。     

Biomechanical comparison of reconstruction techniques for disruption of the acromioclavicular and coracoclavicular ligaments

Injuries to the acromioclavicular joint are common. For selected injuries, operative reconstruction is recommended. The purpose of the current study was to compare three reconstruction procedures: (1) nine strands of woven polydioxanonsulphate (PDS II) suture passed through the clavicle and around the coracoid; (2) procedure No. 1 with 50% of the coracoacromioclavicular ligament placed through 2 clavicular drill holes; (3) No. 5 Merselene tape passed through 2 drill holes in the clavicle and acromion, with 50% of the coracoacromial ligament transferred to the clavicle. Fourteen fresh frozen human shoulders were tested using a 6 degree-of-freedom testing device. The intact shoulder showed significantly less displacement than any of the reconstructions. Merselene tape plus ligament showed the largest displacement, and PDS II braid plus ligament showed the least displacement. None of the procedures reconstituted acromioclavicular joint stiffness to intact state levels, though improved acromioclavicular joint stiffness was noted with a PDS braid plus ligament.     

A cadaveric study examining acromioclavicular joint congruity after different methods of coracoclavicular loop repair

A basic principle in the treatment of joint injuries is to restore congruity with the hope that restoration may lessen the incidence of late arthritis. The acromioclavicular (AC) joint is frequently injured. Many AC joint injuries are treated nonoperatively; others are treated surgically. Coracoclavicular loop repair of the AC joint is believed to lead to anterior displacement of the clavicle relative to the acromion. This cadaveric study evaluated the effectiveness of three techniques of coracoclavicular loop repair in restoring AC joint congruity through measurement of anterior displacement. Fourteen shoulders were repaired by the three different techniques, all of which consisted of fixation through a drill hole in the clavicle and around the crook of the coracoid with a suture. The techniques only varied by the placement of the drill hole in the clavicle (ie, either posterior, middle, or anterior). The results of this study indicate that as the drill hole moved anteriorly on the clavicle, joint congruity was more closely approached and less anterior displacement of the clavicle occurred. However, none of the methods of coracoclavicular loop fixation restored full AC joint congruity.     

TightRope治疗Rockwood Ⅲ型肩锁关节脱位失败病例分析

目的分析TightRope治疗肩锁关节脱位失败病例的原因,总结相关经验教训。 方法自2014年1月至2018年4月收治肩锁关节脱位RockwoodⅢ型77例,均采用TightRope重建喙锁韧带治疗,术后发生钢板脱出、松动共6例,分析其手术失败原因。 结果所有患者均获随访,随访时间3~32个月,平均14.30个月,术后3个月Constant评分（93.86±5.59）分。失败病例6例,术后3个月Constant评分（79.17±7.33）分。失败原因包括隧道建立偏斜3例,手术操作不当2例,肩锁关节过度复位1例。 结论TightRope治疗肩锁关节脱位导致失败的因素：严重的骨质疏松,隧道建立偏斜,过度复位等。     

应用缝合锚钉解剖重建肩锁关节的临床效果

目的评估应用缝合锚钉重建喙锁韧带,治疗急性肩锁关节脱位的临床结果。 方法自2014年2月至2015年6月接受手术治疗的急性肩锁关节脱位患者13例,其中男性8例、女性5例;平均年龄为（40.0±15.6）岁。应用缝合锚钉重建喙锁韧带,复位固定肩锁关节。术后应用三维CT评估喙突上缝合锚钉的位置情况;通过肩关节正位片评估肩锁关节复位保持情况,并测量喙锁间距;记录肩关节的活动范围、视觉模拟评分（visual analogue scale,VAS）和Constant-Merly评分。 结果所有患者均顺利康复。术后肩关节前屈上举平均为171.5°,体侧外旋为70.8°,体侧内旋为T8。VAS评分为（0.3±0.6）分,Constant-Merly评分为92.4分。术后术侧的喙锁间距平均为（8.9±3.0）mm,健侧的喙锁间距平均为（7.7±1.7）mm,两者之间差异无统计学意义（P=0.119）。26枚锚钉中有23枚位置良好,1枚锚钉刺穿了喙突的下表面,2枚锚钉位置偏向内侧。1例患者肩锁关节复位完全丢失,1例患者肩锁关节复位部分丢失,其Constant-Merly评分分别为74分和84分。 结论通过在喙突基底部准确地置入缝合锚钉,可以解剖重建喙锁韧带,恢复肩锁关节的垂直和水平稳定性。该技术创伤小,可以取得较为满意的临床结果。     

A modified method of coracoid transposition for the treatment of complete dislocation of acromioclavicular joint

Objective:To eport a new method of coracoid transpostiton for the treatment of complete dislocation of acromioclavicular joint and to evaluate its efficacy.Methods:We modified Eewar‘s surgical method as follows:(1)Two small incisions,a transversal incision on the acromioclavicular joint and a longitudinal incision on the coracoid ,were made instead of a conventional large arc incision from the acromion to coracoid.(2)The foreign body in the acromioclavicular joint was cleared out.Thechondral surface at the lateral segment of clavicle was resected to form a pseudarthrosis and meanwhile the residual joint capsule and ligaments were repaired.(3)The coracoid was moved to the anteroinferior edge of the clavicle instead of the anterior margin and (4)the coracoid was moved to the lateral border of the clavicle instead of the superior border of the coracoclavicular ligament.Results:The follow-up duration in 30patients of the series was from6to 72months(mean41months).Functional assessment was carried out by the criteria delineated previously by Karkson,in which Grade Awas in 24 cases,Grade Bin4cases,and Cin2.Conclusions:This modified technique,having less postoperative complications and less injuries to tissues and according well with the requitement of biomechanics,can achieve a stable reduction of acromioclavicular joint with a good functional and cosmetic result and thereore is preferable to use clinically on a large scale.     

Arthroscopic Treatment of Acute and Chronic Acromioclavicular Joint Dislocation

This article presents an all-arthroscopic technique for coracoclavicular ligament reconstruction by ligamentoplasty after acute or chronic acromioclavicular joint dislocation. A coracoacromial ligament transfer is done to reconstruct the torn coracoclavicular ligaments, similar to open surgery. The coracoacromial ligament is dissected from the undersurface of the acromion and is reinserted on the inferior clavicle by transosseous suture fixation. Additional wire or screw stabilization may be used. With this method, we achieve a very satisfactory reduction of the dislocated acromioclavicular joint.     

肩锁关节解剖学研究和临床意义

目的研究肩锁关节骨性和静态稳定结构,为肩部手术提供详细形态学资料。方法对26例成人新鲜尸体标本进行解剖,观察肩锁关节解剖形态并测量相关骨性标志和韧带的形态学参数。结果锥状韧带和斜方韧带锁骨止点中心到锁骨远端距离分别为(43.67±6.30)mm和(25.25±3.06)mm,止点宽度分别为(16.92±4.25)mm和(10.33±1.32)mm。锥状韧带长度为(15.54±3.32)mm,角度为(-116.25±10.90)°;而斜方韧带长度为(9.63±2.28)mm,角度为(75.42±11.37)°。锥状韧带和斜方韧带喙突止点相距(8.96±3.00)mm,而锁骨止点距离(13.08±3.50)mm,两条韧带呈"V"形结构。结论本研究获得了肩锁关节及其周围组织的详细形态学参数,为该部位手术提供解剖学资料。进行锁骨远端手术时应避免损伤锥韧带和斜方韧带止点,切除锁骨远端应不超过10mm以避免损伤斜方韧带。行喙锁韧带重建时要注意重建其"V"形解剖结构,以更好恢复其生理功能。     

Biomechanics and comparison of two operative methods of treatment of complete acromioclavicular separation

Sixty-three complete acromioclavicular separations were treated by 2 operative methods. Acromioclavicular wiring gave 73% acceptable results while wire or Dacron coracoclavicular loop gave 94% acceptable results. Complications, especially broken, bent, or backed-out wires were common with acromioclavicular wiring. Of 44 patients treated by acromioclavicular wiring, 5 required late distal clavicle resection and 4 of these had retained menisci. Loop fixation is mechanically superior since the loop is in the direction of the tensile forces. In acromioclavicular wiring, however, the fixation Kirschner wires are subjected to high bending moments. Loop fixation avoids violation of the acromioclavicular joint but does not restrict rotation of the clavicle. The operation is simple to perform and postoperative immobilization is minimal. Woven Dacron may be superior to surgical wire for loop fixation in that unlike wire it does not require removal by a second operation. Woven Dacron may also stimulate coracoclavicular ligament reconstitution.     

Current concepts in management of ACJ injuries

Acromioclavicular joint injury is common in young individuals who suffer direct trauma to the shoulder. Treatment of acromioclavicular dislocation is controversial with regards to the indication of operative management, timing of surgery, whether to perform open or arthroscopic surgery, method of stabilisation (rigid or non-rigid) and type of graft used for repair or reconstruction. Current evidence supports conservative management for Rockwood types I and II, while types IV, V and VI benefit from surgery. The optimal management of type III injuries in high demand patients remains contentious. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Few studies with a low level of evidence suggest arthroscopic techniques and anatomical ligament reconstruction have better outcomes when compared to older techniques of rigid coracoclavicular fixation. The aim of this article is to look at the current evidence and address these controversial issues.     

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。     

A biomechanical comparison of suture constructs used for coracoclavicular fixation

There is no consensus regarding surgical treatment for severely dislocated acromioclavicular joints. Although many treatments are suture-based, the suture materials and resulting suture-bone constructs have been subjected to limited systematic evaluation. This study identifies the strongest and least deforming suture construct among those commonly used for such repairs. Each suture-based repair was tested on a simulated clavicle and coracoid process with the skeletal components distracted until the suture failed to obtain tensile strength. Additional groups of sutures were subjected to cyclic loading to determine resistance to deformation. Panacryl braid had significantly greater tensile strength than all other constructs: Polydioxanone (PDS) braid, Mersilene tape, and Ethibond #5. Deformation after cyclic loading of Panacryl braid, PDS braid, and two strands of Mersilene tape was significantly less than that of the other constructs. A bioabsorbable suture loop, such as Panacryl, can act as a temporary internal splint, maintaining acromioclavicular joint reduction long enough for ligamentous healing during rehabilitation, and can avoid complications associated with permanent fixation materials. Panacryl braid deserves serious consideration for coracoclavicular fixation because of its strength, resistance to deformation, and bioabsorbable properties.     

A Modified Technique of Arthroscopically Assisted AC Joint Reconstruction and Preliminary Results

Surgical treatment of high-grade acromioclavicular (AC) joint separations has become analogous to ligament reconstructions elsewhere in the body with the goal being restoration of the native anatomy. Circumferential access to the base of the coracoid is essential to reconstruct the coracoclavicular ligament complex. Using some of the traditional open approaches, this access requires detaching the deltoid insertion and performing extensive soft tissue dissection. Also, poor visualization risks injury to nearby neurovascular structures. An arthroscopically assisted reconstruction offers the advantage of less soft tissue dissection and superior visualization to the base of the coracoid. We have developed a unique arthroscopically assisted technique that uses a subacromial approach to pass suture material and a tendon graft around the coracoid to reconstruct the coracoclavicular ligament complex. We describe our technique and preliminary results in 10 patients who have undergone coracoclavicular ligament reconstruction for high-grade AC separation. All patients improved subjectively with regard to pain and function at a minimum followup of 3 months (mean, 5 months; range, 3-18 months). This arthroscopically assisted technique has the potential to allow for safe and at least in the short term reliable restoration of the coracoclavicular ligament complex and provides an alternative technique to treat AC joint separations.     

关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位

目的探讨关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位的临床疗效。 方法回顾性分析上海交通大学医学院附属新华医院骨科采用关节镜辅助下三束重建治疗21例急性Rockwood Ⅲ型肩锁关节脱位患者的资料,均为闭合性损伤。术后3、6、12个月对所有患者进行术后临床效果和影像学评价。根据术后影像学资料评估复位再丢失情况,采用Constant评分和上肢功能（disabilities of arm,shoulder and hand,DASH）评分评估患者肩关节功能。探讨术中关节镜辅助治疗的意义和价值。 结果术中关节镜探查发现4例合并软组织损伤,并进行一期镜下修复。所有患者术后均未发生喙突骨折和襻断裂。影像学评估提示术后6~12个月有6例患者（28.6%）出现轻度复位丢失,但与Constant评分和DASH评分无显著相关性,没有患者要求取出内固定。 结论关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位是一种创伤小、安全、临床效果确切的手术方法。急性肩锁关节脱位通常由高能量损伤造成,在手术中关节镜探查肩关节能发现合并的软组织损伤,并进行一期修复,有利于肩关节功能的恢复,避免二次手术。     

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。