喙锁韧带的影像学分析

目的 研究喙锁韧带的影像学表现.方法 选取正常胸部正位CR片400例,其中男、女各200例,观察喙锁关节和喙锁韧带附着处锁骨粗隆显示率,测量喙锁韧带部喙突和锁骨间距.选取正常肩关节MRI 30例,观察喙锁韧带显示率和测量喙锁韧带长度和宽度;选取临床已证实的肩锁关节Ⅱ、Ⅲ级损伤MRI检查8例.结果 400例800侧中见1例(0.25%)存在喙锁关节.198 侧(198/800;24.8%)显示喙锁韧带锁骨附着处粗隆存在.正常喙突锁骨间距为(6.92±3.16) mm.30例正常人MRI斜冠状扫描均可显示喙锁韧带,其锥状韧带长度(11.48±1.43) mm,宽度为(4.82±1.21) mm,梯状韧带长度(9.09±0.84) mm,宽度为(5.10±0.87) mm.肩锁关节损伤8例,MR检查发现:肩锁关节Ⅱ级损伤肩锁韧带撕裂,Ⅲ级损伤并喙锁韧带撕裂.结论 本文建立了正常喙锁韧带的X线和MRI测量标准,为诊断喙锁韧带等疾病提供了依据,肩锁关节Ⅲ级损伤有喙锁韧带撕裂.     

高原地区锁骨肩峰端骨折两种手术方法的疗效比较

目的 对比四川高原地区锁骨肩峰端骨折运用微创经皮钢板内固定技术（minimally invasive percutaneous plate osteosynthesis,MIPPO）与传统张力带钢丝固定手术的临床疗效.方法 选择40例高原地区锁骨肩峰端骨折患者,随机分为MIPPO治疗组和张力带钢丝固定对照组,分析两组间疗效是否有统计学差异.结果 术后关节功能评定,MIPPO组优17例,良2例,差1例,优良率95.0％;对照组优9例,良8例,差3例,优良率85.0％,两组疗效整体比较,MIPPO组优于对照组（x2CMH=5.449,P=0.0196）.结论 高原地区MIPPO技术治疗锁骨肩峰端骨折,疗效确切,为治疗高原地区肩峰端骨折提供了新的思路.     

Biomechanical rationale for development of anatomical reconstructions of coracoclavicular ligaments after complete acromioclavicular joint dislocations

BACKGROUND: Surgical treatments of complete acromioclavicular joint dislocations replace or reconstruct the coracoclavicular ligaments with a single structure and do not account for the anatomical variance of each ligament in the design. PURPOSE: To evaluate the cyclic behavior and structural properties of an anatomic tendon reconstruction of the coracoclavicular ligament complex after a simulated acromioclavicular joint dislocation. STUDY DESIGN: Controlled laboratory study. METHODS: Cyclic loading followed by a load-to-failure protocol (simulated dislocation) of the normal coracoclavicular ligament complex was performed and repeated after an anatomic reconstruction on the same specimen (n = 9). The anatomical reconstruction consisted of a semitendinosus tendon that replicated the direction and orientation of both the trapezoid and conoid ligaments. RESULTS: The coracoclavicular ligament and anatomical reconstruction complexes had clinically insignificant (<3 mm) permanent elongation after cyclic loading. The stiffness and ultimate load of the coracoclavicular ligament complex (60.8 +/- 12.2 N/mm and 560 +/- 206 N) were significantly greater than for the anatomical reconstruction complex (23.4 +/- 5.2 N/mm and 406 +/- 60 N), respectively (P < .05). Further analysis of the complexes revealed a 40% decrease in the bending stiffness of the clavicle after the simulated dislocation and failure of the normal coracoclavicular ligament complex (P < .05), which contributed to the diminished properties of the anatomic reconstruction. CONCLUSIONS: The low level of permanent elongation after cyclic loading suggests that the anatomic reconstruction complex could withstand early rehabilitation; however, the decrease in the structural properties and stiffness of the clavicle should be considered in optimizing the anatomic reconstruction technique. CLINICAL RELEVANCE: Despite the differences compared to the normal coracoclavicular ligament complex, the anatomical reconstruction complex more closely approximates the stiffness of the coracoclavicular ligament complex than current surgical constructs, and the incorporation of biological tissue could improve the overall structural properties with healing.     

改良Weaver法治疗肩锁关节脱位

完全性肩琐关节脱位常伴有喙锁韧带断裂，我院自１９９１－１９９６年５年间对１８例Ⅲ度肩锁关节新鲜脱位伴喙锁韧带断裂者行切开复位克氏针内固定和喙肩韧带移行代替喙锁韧带（改良Ｗｅａｖｅｒ）手术，取得满意疗效。术后随访平均２４个月，无脱位或半脱位发生，依Ｌａｚｚｃａｎｏ标准评定：优１７例，良１例。     

Biomechanics of the coracoclavicular ligament complex and augmentations used in its repair and reconstruction

Augmentation is a well-accepted and common component of coracoclavicular ligament repairs and reconstructions. The purpose of this study was to examine and compare the strength, stiffness, and mode of failure of the coracoclavicular ligament complex and four different augmentation techniques in cadaveric shoulders. There was no significant difference in the mean failure load between the intact ligament complex (724.9+/-230.9 N) and augmentations performed with braided polydioxanone (PDS) (676.7+/-115.4 N) or braided polyethylene placed through (986.1+/-391.1 N) or around (762.7+/-218.2 N) the clavicle. The mean failure load for augmentations using a 6.5-mm cancellous screw through the clavicle and into a single cortex of the coracoid (390.1+/-253.6 N) was significantly lower than that for the intact coracoclavicular ligaments. There was no difference in mean stiffness between the intact coracoclavicular ligament complex (115.9+/-36.2 N/mm) and the braided polyethylene augmentations placed through (99.8+/-22.2 N/mm) or around (90.0+/-25.5 N/mm) the clavicle. Polydioxanone augmentations were significantly less stiff (27.4+/-3.3 N/mm) than the intact complex, while screw augmentations were significantly stiffer (250.4+/-88.2 N/mm). There were no significant differences in strength or stiffness of braided polyethylene reconstructions placed around or through a drill hole in the clavicle.     

Management of distal claviclefractures

The treatment of distal clavicle fractures remains controversial. Successful management relies on the surgeons abilityto accurately classify these injuries. An understanding of the pertinent anatomy coupled with a precise radiographic evaluation will assist the physician in this task. Neer's classification scheme is the most commonly used and is based on the fracture location and the integrity of the coracoclavicular (CC) ligaments. Distal clavicle fractures with intact CC ligaments (Types I and III) are seldom displaced and for this reason are usually amendable to nonoperative treatment. Fractures that occur in conjunction with CC ligament disruption (Type II) are usually displaced making them more susceptible to nonunion and for this reason most are treated operatively. This report will discuss the radiographic evaluation, classification, and treatment rationale for each type of distal clavicle fracture.     

喙肱肌腱转位修复肩锁关节脱位的解剖学基础

用31侧常规防腐成人上肢标本,对喙肱肌腱的形态及喙突的局部结构进行解剖学观测;测量34例锁骨干骨的有关数据;2侧标本行摹拟手术实验。结果：喙肱腱长（87±1．6）cm,喙突尖至锁骨最近距离为（2．4±0．5）cm,喙突尖至锁骨后峰端（43±0．4）cm,喙突粗隆处的锁骨及锁骨肩峰端厚度均为（1．0±0．2）cm。提示,设计橡防肌肤转位修复肩锁关节脱位具有可行性。     

Unusual fracture of distal third of the clavicle in a hockey player: case report and a new approach to treatment

Clavicle fractures represent 5% of all skeletal injuries, and the distal third of the clavicle is involved in approximately 10%–15% of all these fractures. The incidence of delayed union or non-union in Neer type II fractures of the distal third of the clavicle is high. The ideal treatment for Neer type II fractures of the distal third of the clavicle is still open to controversy. Several treatments have been proposed, but there is no consensus about the treatment of choice. The case reported here presents a unique type of fracture of the lateral end of the clavicle that, since a medial fragment is involved, is a Neer type II fracture, but because of the nature of the fracture line the coracoclavicular ligaments remained intact. Trans-bony suture between the two fracture fragments was perfomed as the only treatment. This treatment has not been previously described and, although it has just been used in a single case, it appears to be an effective, efficient and simple alternative for the treatment of Neer type II fractures of the distal third of the clavicle. Received: 9 November 1997 Accepted: 1 March 1998     

双带袢钢板技术治疗NeerⅡ型锁骨远端骨折的疗效分析

目的探讨双带袢钢板技术治疗NeerⅡ型锁骨远端骨折的效果。方法回顾性分析2010年5月—2014年5月核工业二一五医院骨一科治疗的21例NeerⅡ型锁骨远端骨折患者资料,男性15例,女性6例;年龄21~58岁,平均37.0岁。骨折分型均为NeerⅡ型锁骨远端骨折,并且喙锁韧带断裂。以喙锁韧带在锁骨止点为中心,沿锁骨走行做切口,直视下用直径为2.0mm克氏针作为导针钻孔贯穿锁骨、喙突,空心钻(直径为4.5mm)顺导针经过锁骨和喙突钻孔,制造出相连的2个骨孔道,测量2个骨孔道连同2个骨孔道之间总长度。将2块带袢钢板环环扣套,用骨科2#线穿引作为引导线,经喙突骨孔道、锁骨骨孔道依次穿过,两边带袢钢板分别悬吊于锁骨上表面与喙突下表面,沿斜方韧带走形用喙突端的引导线穿过锁骨远端的另一个孔道打结绑扎。术后1、6个月,按照Constant-Muley肩关节功能评分系统评定疗效。结果术后随访时间6~30个月(平均12.0个月)。术后随访X线片示骨折复位良好。骨折愈合时间为5~12周,平均6.5周。术后2个月复查所有患者均恢复肩部活动。术后1个月Constant-Muley评分:优1例,良13例,差7例,平均为83.5分(64~91分);术后6个月,优19例,良2例,平均为93.0分(89~98分)。末次随访时未出现肩部疼痛、感染及骨折错位、延迟愈合等并发症。结论采用双带袢钢板技术治疗NeerⅡ型锁骨远端骨折效果良好,值得推广。     

A modified technique of reconstruction for complete acromioclavicular dislocation: a prospective study

BACKGROUND: Many procedures, both nonoperative and operative, have been described for treatment of complete acromioclavicular dislocations. The best primary treatment, however, still remains unclear. PURPOSE: We present a new surgical technique in which the clavicle is reduced to an anatomic position, the coracoacromial ligament is transferred to the clavicle, and acromioclavicular joint fixation is accomplished with the use of absorbable, braided suture cord. METHODS: Twenty-one patients underwent the modified technique of reconstruction. Patients were included only if they had sustained a Rockwood type V acromioclavicular dislocation and were extremely active in competitive sports before dislocation occurred. RESULTS: Eighteen patients returned to their sports without pain within 2.5 months after operation. The mean follow-up was 35.7 months. The average Constant score at last follow-up was 97. Radiographs taken at this time confirmed anatomic reduction in 18 patients, residual subluxation in 2 patients, and, in 1 patient, redislocation of the joint that occurred because of infection. Six patients had radiographic evidence of coracoclavicular ossifications. All patients developed a wide scar. CONCLUSIONS: Considering its operative simplicity, the advantage of absorbable augmentation of the clavicular reduction, and the low rate of recurrence, this technique may be an attractive alternative in this particular group of patients.     

锁骨钩钢板治疗肩锁关节脱位和锁骨远端骨折

目的　探讨治疗肩锁关节脱位和锁骨远端骨折的新方法。　方法　分析自 2 0 0 0年7月至 2 0 0 1年 5月用锁骨钩钢板治疗TossyⅢ型肩锁关节脱位和锁骨外侧端骨折共 12例的疗效。结果　所有患者均获得良好复位和固定 ,患者的肩关节在术后 2周平均屈曲 90° ,外展 90°。有 1例因钢板预弯不佳发生肩关节撞击 ,但在内固定取出后关节功能未受影响。术后X线评估复位率达10 0 %。内固定取出后 ,无再脱位的病例 ,关节功能恢复良好率 10 0 %。　结论　锁骨钩钢板是治疗肩锁关节脱位和锁骨远端骨折的一种可靠的方法。     

Acromioclavicular joint instability—reconstruction indications and techniques

Injuries to the acromioclavicular joint are common and may lead to instability or degenerative changes requiring surgical intervention. The spectrum of injury ranges from sprain to disruption of the acromioclavicular and coracoclavicular ligaments, which provide horizontal and vertical stability to the distal clavicle. Most injuries are the result of direct trauma to the acromioclavicular joint. The majority of injuries can be nonoperatively managed. However, with significant disruption to the surrounding supportive structures, painful instability may result. Multiple stabilization procedures for the acromioclavicular joint have been described. Many of these techniques have fallen out of favor due to high complication rates. Common reconstruction techniques include either coracoclavicular ligament reconstruction with or without clavicle resection (ie, modified Weaver-Dunn) or coracoclavicular stabilization (ie, with Bosworth screw) with repair or reconstruction of the coracoclavicular ligaments. The purpose of this paper is to review the basic anatomy, biomechanics, and treatment of acromioclavicular joint instability.     

喙锁韧带重建与锁骨钩钢板治疗RockwoodⅢ型肩锁关节脱位手术效果比较

目的对比研究喙锁韧带重建与锁骨钩钢板治疗RockwoodⅢ型肩锁关节脱位手术效果。方法回顾性分析2013年3月~2015年2月收治的36例RockwoodⅢ型创伤性肩锁关节脱位患者的临床资料,其中男性27例,女性9例;年龄19~32岁,平均24.7岁。18例行喙锁韧带带袢钢板(Endobutton)重建手术治疗(A组),18例行锁骨钩钢板手术治疗(B组)。对两组患者手术时间、术后疼痛视觉模拟评分(visual analogue scale,VAS)及Constant-Murley肩关节功能评分方面进行比较分析。结果两组患者平均手术时间分别为(59±4)min(A组)、(54±6)min(B组),两组间差异没有统计学意义(P=0.596);术后VAS分别为(1.8±0.7)分(A组)、(1.5±1.1)分(B组),差异无统计学意义(P=0.612);术后12周患者ConstantMurley肩关节功能评分分别为(91±3.7)分(A组)、(83±6.2)分(B组),B组患者的肩关节功能评分较A组低,两组间评分差异有统计学意义(P=0.027)。结论采取Endobutton悬吊重建喙锁韧带功能,固定肩锁关节脱位,更好地恢复了肩锁关节作为微动关节的生物力学及运动轨迹,未增加手术时间及导致创伤,肩关节功能恢复良好,较锁骨钩钢板是一种更理想的手术方式。     

喙锁螺钉与双Endobutton钢板治疗肩锁关节脱位的临床研究

目的 探讨喙锁螺钉与双Endobutton钢板治疗Rockwocd Ⅲ～Ⅴ型肩锁关节脱位的临床疗效,并对两者进行对比研究.方法自2008年1月至2009年10月收治Rockwood Ⅲ～Ⅴ型肩锁关节脱位患者28例,电脑随机抽样分为两组,14例采用喙锁螺钉治疗,另14例采用双Endobutton钢板治疗.采用Constant评分和自我评分系统(subject should value,SSV)评价肩关节功能,并对两组临床疗效、影像学结果及并发症进行对比研究.结果两组患者术后均获6～25个月随访,平均12.6个月,术后Constant评分和SSV评分均优于术前(P＜0.05),但术后Constant评分和SSV评分双Endobutton钢板组分别以(89.8±8.3)分、(85.7±7.3)分明显优于喙锁螺钉组的(78.0 ±10.3)分、(71.8±9.7)分(P＜0.05),术后3个月两组影像学测量差异无统计学意义(P＞0.05).结论 双Endobutton钢板治疗Rockwood Ⅲ～Ⅴ型肩锁关节脱位的临床疗效优于喙锁螺钉治疗,其通过解剖方式重建喙锁韧带将成为治疗肩锁关节脱位的未来发展趋势.

Abstract：

Objective To evaluate and compare the clinical outcome of coracoclavicular screw and double Endobutton plate in treatment of acromioclavicular dislocation ( Rockwood Ⅲ-Ⅴ ). Methods Twenty-eight patients with Rockwood Ⅲ-Ⅴ acromioclavicular dislocation were subjected to surgical reconstruction from January 2008 to October 2009. The coracoclavicular screw was performed in 14 patients and the double Endobutton plate in the other 14 patients. Clinical evaluation was performed by using Constant score and subject should value (SSV) in both groups, and the preoperative and postoperative radiographs, curative effects and complications were compared. Results The patients in two groups were followed up for a range of 6-25 months (average 12.6 months) , which showed higher postoperative Constant score and SSV score than preoperation in both groups (P＜0.05). But the postoperative Constant sore and postoperative SSV score in the double Endobutton group were (89.8 ±8.3) points and (85.7 ±7. 3) points respectively, significantly better than (78. 0 ± 10. 3) points and (71. 8 ±9. 7) points respectively in the coracoclavicular screw group ( P ＜ 0.05). The radiologic measurement showed no significant difference in regard of the coracoclavicular distance three months after operation in two groups (P＞0.05). Conclusions The double Endobutton plate can attain significantly superior clinical outcomes for Rockwood Ⅲ-Ⅴ acromioclavicular dislocation compared with the coracoclavicular screw. The surgical technique of reconstructing the coracoclavicular ligament through anatomical approach will be the future trend in treatment of the acromioclavicular joint dislocation.     

Evaluation and treatment of distal clavicle fractures

Of all clavicle fractures, those involving the lateral aspect are the most controversial. These fractures, adjacent to the strong coracoclavicular ligaments, often create an imbalance of stability and motion between the proximal and distal fragment. There are many surgical options, but the complication rates of these procedures can be high. Although nonsurgical management results in relatively high nonunion rates, the subjective and functional outcome is usually quite good. The evaluation and controversies involving management of distal clavicle fractures are reviewed in this article.     

锁骨钩钢板治疗Ⅲ型肩锁关节脱位及锁骨肩峰端骨折的疗效分析

目的探讨锁骨钩钢板治疗Ⅲ型肩锁关节脱位及锁骨肩峰端骨折的疗效。方法对31例Ⅲ型肩锁关节脱位及锁骨肩峰端骨折应用锁骨钩钢板治疗的临床资料进行回顾性分析。结果31例患者中仅2例拆除内固定后出现了轻度脱位现象,对功能无影响,手术优良率达100%。结论锁骨钩钢板治疗Ⅲ型肩锁关节脱位及锁骨肩峰端骨折是一种快捷、有效的方法。     

Unique distal clavicular fracture in an active-duty military population

We present a series of distal clavicle fractures in which the coracoclavicular ligaments remain intact to the proximal segment, but the distal aspect of the clavicle is displaced superiorly. The fractures sustained in this series are not described in any of the multiple classification systems currently in use for clavicular fractures. We present a series of 2 active-duty patients who sustained nearly identical distal clavicle fractures during Army combatives training. A 23-year-old male was treated successfully with nonoperative therapy and returned to deployment within 2 months. A 23-year-old female failed nonoperative treatment and was successfully treated with an operative open distal clavicle resection. This rare fracture attributed to a specific mechanism of injury has a potential to be commonly encountered in active-duty patients taking part in mandatory combatives programs.     

锁骨钩钢板治疗肩锁关节脱位和锁骨远端骨折63例

目的探讨锁骨钩钢板对肩锁关节脱位和锁骨远端骨折的治疗效果。方法回顾性分析63例锁骨钩钢板治疗肩锁关节全脱位和NeerⅡ型锁骨远端骨折临床资料,其中肩锁关节全脱位41例(锁骨远端骨折合并肩关节脱位7例),锁骨远端骨折22例。结果所有患者获得良好复位和固定,X线片未见肩锁关节半脱位或钢板断裂和松动,肩关节功能恢复良好,内固定取出后无再脱位及再骨折现象。结论锁骨钩钢板是治疗肩锁关节脱位和锁骨远端骨折的一种良好方法。     

Arthroscopic reconstruction of chronic AC joint dislocations by transposition of the coracoacromial ligament augmented by the Tight Rope device: a technical note

We present a new arthroscopic technique for chronic AC joint dislocations with coracoacromial ligament transposition and augmentation by the Tight Rope device (Arthrex, Naples, USA). First the glenohumeral joint is visualised to repair concomitant lesions, such as SLAP lesions, if needed. Once the rotator interval is opened and the coracoid is identified, the arthroscope is moved to an additional anterolateral portal. A 1.5 cm incision is made 2 cm medial to the AC joint. After drilling a 4 mm hole with a cannulated drill through the clavicle and coracoid a Tight Rope is inserted, the clavicule is reduced and stabilized with the implant. The arthroscope is moved to the subacromial space and a partial bursectomy is performed to visualise the CA ligament and lateral clavicle. The CA ligament is armed with a strong braided suture using a Lasso stitch and dissected from the undersurface of the acromion. It is then reattached to the distal part of the clavicle by transosseous suture fixation after abrasion of its undersurface. Although this combined arthroscopic procedure of AC joint augmentation with a Tight Rope combined with a ligament transposition is technically demanding, it is a safe method to reconstruct the coracoclavicular ligaments and achieve a sufficient reduction of the clavicle without the need of further implant removal or autologous tendon transplantation.