Minimally Invasive Coracoclavicular Ligament Augmentation With a Flip Button/Polydioxanone Repair for Treatment of Total Acromioclavicular Joint Dislocation

Treatment of complete acromioclavicular joint disruption remains controversial and ranges from rehabilitation to extensive surgical reconstruction. However, high-grade injuries (type IV, V, and VI) are typically treated surgically. Most reconstruction techniques addressing these injuries selectively focus on coracoclavicular ligament augmentation because it has been shown to be the primary stabilizer of the acromioclavicular joint. The conventional coracoclavicular polydioxanone (PDS) loop, which is widely performed, has been detected to have some pivotal disadvantages, including anterior subluxation of the clavicle, extensive preparation of the coracoid, and bony avulsion of the clavicle as a result of rotational clavicle movement. Therefore we present an augmentation technique that reduces these complications by replicating the orientation of the native coracoclavicular ligament complex and providing a minimally invasive subcoracoid and clavicular fixation of a double PDS loop by use of 2 flip buttons, typically used for extracortical anterior cruciate ligament graft fixation. The key step of the procedure includes the anatomic, secure, and stable placement of the double PDS cerclage under the coracoid base transferring a flip button through a coracoid bone tunnel. Our clinical experience shows that the presented technique is easy to perform and has a comparable invasiveness to recently presented arthroscopic techniques.     

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。     

Distal clavicular physeal injury

Fourteen patients with separation of the distal clavicular metaphysis from the epiphysis were reviewed. These injuries, especially in the older child and adolescent, mimic acromioclavicular separation. However, they are really growth-plate injuries in which the epiphysis and physis maintain their normal anatomic relation to the shoulder joint, while the distal metaphysis is displaced superiorly, away from the underlying structures. The periosteal sleeve is generally intact inferiorly, and the ligamentous structures connecting the clavicle to the coracoid usually remain attached to the periosteal sleeve. Depending on the degree of displacement, these patients may be treated by either closed methods or pin fixation. The periosteal sleeve is usually extremely osteogenic and will readily fill in any gap between the periosteum and metaphysis. In fact, in one patient this led to clavicular "duplication" and necessitated resection of the original distal clavicle. In the skeletally immature patient it is extremely important to recognize that these physeal injuries are discrete from acromioclavicular separation.     

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。     

Arthroscopic Stabilization of Neer Type 2 Fracture of the Distal Part of the Clavicle

With regard to the anatomic basis of Neer type 2 fractures of the distal part of the clavicle, a clavicle fracture is associated with a coracoclavicular conoid ligament disruption. We describe an arthroscopic-assisted surgical procedure to stabilize the fracture and reconstruct the ligament. Surgery is performed with the patient in the beach-chair position. Through a 2-cm incision perpendicular to the direction of the fracture, we perform suturing around the fracture. During the arthroscopic procedure, the coracoid process is exposed by opening the rotator interval and the medial part of the capsule. The knee of the coracoid process should be exposed via an anterolateral portal for the arthroscope. Then, by use of an acromioclavicular joint stabilization device from Arthrex (Naples, FL), a hole is placed through the knee of the coracoid process. FiberTape suture (Arthrex) is passed around the clavicle and through the knee of the coracoid process. The intra-articular sutures are pulled out through the upper incision on top of the clavicle. Tightening of the 2 knots is performed at the same time. This arthroscopic-assisted surgery allows for total recovery of shoulder function, without the inconvenience of device migration or acromioclavicular joint lesions reported with other procedures.     

Arthroscopic Coracoclavicular Ligament Reconstruction Using Biologic and Suture Fixation

Presented in this report is a modified arthroscopic approach to acromioclavicular joint reconstruction via suture and allograft fixation. An arthroscopic approach is used to expose the base of the coracoid by use of electrocautery. After an open distal clavicle excision is performed, clavicular and coracoid tunnels are created under arthroscopic visualization as previously described by Wolf and Pennington. The myotendinous end of a semitendinosus allograft is sutured to a Spider plate (Kinetikos Medical, San Diego, CA). The tendinous end of the graft is prepared with a running baseball stitch. A Nitinol wire with a loop end (Arthrex, Naples, FL) is used to pass 2 free FiberTape sutures (Arthrex) and the leading sutures from the tendinous end of the graft through the clavicular and coracoid tunnels, exiting out the anterior portal. One of the FiberTape sutures is retrieved with a grasper and passed over the anterior aspect of the distal clavicle. The second FiberTape suture and the allograft are passed over the distal end of the resected clavicle. While the acromioclavicular joint is held reduced, the FiberTape sutures are tied to the plate and the allograft is tensioned medially until the plate is embedded against the superior surface of the clavicle. The tendinous end of the graft is secured to the superior surface of the clavicle with a Bio-tenodesis screw (Arthrex) medial to the clavicular tunnel.     

Concomitant Acromioclavicular and Coracoclavicular Ligament Reconstruction with a Duo-Figure-8 Autogenic Graft Wrapping Technique for Treating Chronic Acromioclavicular Separation

BackgroudCoracoacromial ligament transfer is the traditional procedure for treating chronic acromioclavicular separation, but it is significantly inferior to ligament reconstruction according to biomechanical and clinical studies. However, ligament reconstruction carries the risk of complications of graft loosening and peri-tunnel fractures. Currently, there is no ligament reconstruction procedure optimal for preventing such complications. The purpose of this study was to describe and retrospectively analyze the clinical and radiological outcomes of a “duo-figure-8” autogenic graft wrapping technique, which was used to concomitantly reconstruct the acromioclavicular and coracoclavicular ligaments.MethodsPreoperative, immediate postoperative, and final follow-up oputcomes were evaluated in 10 enrolled patients. Radiographic outcomes were indicated by the bilateral difference of the coracoclavicular distance (CCD) and overlapping length of the acromioclavicular joint (OLac). Quality of reduction was classified into 4 grades according to bilateral CCD difference into overreduction (< 0 mm), anatomic reduction (0–4 mm), partial loss of reduction (4–8 mm), and recurrent dislocation (> 8 mm). Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) and Constant scores.ResultsThe mean side-to-side differences for CCD were 11.9 mm (preoperative), −0.1 mm (immediate postoperative), and 3.4 mm (final follow-up); those for OLac were 9.4 mm (preoperative) and 2.7 mm (final follow-up). CCD and OLac outcomes significantly improved at final follow-up (p < 0.05). At the immediate postoperative stage, 6 and 4 patients had overreduction and anatomic reduction, respectively. At final follow-up, 7 and 3 patients had anatomic reduction and partial loss of reduction, respectively. The magnitude of improvement of ASES scores for patients with anatomic reduction and partial loss of reduction (p = 0.20) was 18.1 and 20.0, respectively. The magnitude of improvement of Constant scores in patients with anatomic reduction and partial loss of reduction (p = 0.25) was 19.9 and 22.3, respectively.ConclusionsThe technique yielded acceptable functional outcomes in patients with anatomic reduction or partial loss of reduction. The “duo-figure-8” wrapping method—a single autogenic tendon graft passing beneath the coracoid process with a tendon-knot fixation over the distal clavicle and looping around the acromion intramedullary—did not increase the risk of peri-tunnel fractures over the clavicle, coracoid process, or acromion.     

Editorial Commentary: Acute Repair of the Acromioclavicular Joint Capsule and Ligaments and Deltotrapezial Fascia Could Allow Biological Healing of High-Grade Acromioclavicular Separation—Coracoclavicular Ligament Graft Augmentation Could Be Indicated if Time to Surgery Is Greater Than 3 Weeks

Surgical management of chronic acromioclavicular joint (ACJ) dislocations is a matter of controversy. In the acute setting of high-grade acromioclavicular separation, if a surgical repair of the ACJ capsule and ligaments and deltotrapezial fascia could allow biological healing of the ligaments themselves, this could be enough to restore the functional biomechanics of the joint; unfortunately, this is not true for chronic cases. In the latter situation, a surgical technique using biological augmentation such as autograft or allograft should be preferred. Time is very important for this injury, and a chronic lesion should be considered when treatment is being performed 3 weeks after trauma. The graft should be passed around the base of the coracoid or through a tunnel at the base of the coracoid itself and then at the level of the clavicle as anatomically possible to reproduce the function of the native ligaments. However, some studies have shown that passing the graft at the base of the coracoid and wrapping it around the clavicle could also achieve satisfactory outcomes. An arthroscopic technique, when used in combination, could be great to treat the associated lesions, which have a reported percentage between 30% and 49%. Finally, to restore the biomechanics of the ACJ, however, reconstruction of the acromioclavicular superior and posterior capsules together with the deltotrapezial fascia seems to be very important.     

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。     

Acromioclavicular Joint Injuries and Distal Clavicle Fractures

The acromioclavicular joint is commonly affected by traumatic and degenerative conditions. Most injuries are due to direct trauma, such as a fall on the shoulder. Six types of acromioclavicular sprains and three types of distal clavicle fractures have been described in adults. Although there is general agreement on treatment of type I, II, IV, V, and VI acromioclavicular injuries, the treatment of type III injuries remains controversial. Studies have shown no distinct advantage for surgical reconstruction over nonoperative treatment. Because type II distal clavicle fractures are prone to nonunion, operative fixation may be advisable to avoid this complication.     

Midshaft clavicle fractures with associated ipsilateral acromioclavicular joint dislocations: Incidence and risk factors

IntroductionSimultaneous ipsilateral clavicle and acromioclavicular (AC) joint injury have been infrequently reported in the literature at this time. The purpose of this study was to assess incidence as well as assess risk factors for this dual injury pattern.MethodsWe performed a retrospective review of a prospectively collected database (Level III evidence), evaluating 383 adult patients without previous shoulder girdle injury or trauma with a minimum 1-year follow-up who sustained a displaced diaphyseal clavicle fracture. All patients in the study underwent either nonoperative management or surgical reduction and stabilization of a diaphyseal clavicle fracture with a plate and screw construct. Study subjects were followed with serial radiographs. Clavicle and shoulder radiographs, as well as chest radiographs and contralateral films in questionable cases, were used to assess for acromioclavicular joint injury in both operative and nonoperative groups. Additional data was collected on concurrent injuries, patient demographics, fracture characteristics, fixation techniques, surgical/post-operative data, and operative or nonoperative treatment.ResultsWe found that 13/183 (7.1%) of patients undergoing fixation of a diaphyseal clavicle fracture had an ipsilateral AC joint injury, while 13/200 (6.5%) of patients undergoing conservative management had an ipsilateral AC joint injury. Critical analysis of the data revealed that presence of ipsilateral scapular body fractures, and a likely incidental association with superior plating fixation, were associated with an increased rate of this injury pattern.ConclusionsIpsilateral clavicle fracture and AC joint injury is much more common than traditionally believed, with an incidence of 6.8% overall. It is unknown how the presence of an associated AC injury influences outcome, as AC injury was not universally symptomatic.     

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.     

Acute acromioclavicular dislocations treated by fixation of the joint and ligament repair or reconstruction

We reviewed 55 patients, median age 34 years, who had had acute complete acromioclavicular dislocation treated by transient acromioclavicular fixation with a Knowles pin and ligament repair by suturing or reconstruction of the superior acromioclavicular ligament with transfer of the coracoid end of the coracoacromial ligament onto the clavicle. At followup examination 50 patients showed at least a satisfactory result. Five cases, two of which had had subsequent resection of the distal end of the clavicle, were classified as poor, mainly because of pain, even though the functional result was good in three. Reconstruction of the superior acromioclavicular ligament, although it improved the anatomic result, was shown to be of no advantage and may even have caused discomfort. The numerous radiological findings of residual subluxation or dislocation, deformity of the distal end of the clavicle, soft tissue calcification and osteoarthritis or pathological physical findings did not correlate significantly with the clinical outcomes. In general this operation gave results comparable with those achieved by other operative methods. It is useful if surgery is preferred to conservative treatment.     

Bipolar fracture dislocation of clavicle: A report of osteosynthesis and early soft tissue reconstruction

IntroductionBipolar dislocation of the clavicle, also called bifocal or pan-articular dislocation or floating clavicle, is an uncommon traumatic injury. The injury of this case is also concomitant with distal third clavicle and coracoid fracture. This article aimed to report the experience of performing osteosynthesis and early soft tissue reconstruction on these injuries.Case reportWe reported a case of bipolar clavicle fracture-dislocation in concomitant with coracoid fracture in a man, aged 32 years old, successfully treated 24 days after accident by fixation of both fractures and early simultaneous reconstruction of sternoclavicular- acromioclavicular-coracoclavicular joints.DiscussionThese injuries are rare and capable of causing many complications if they are treated improperly. It is compulsory to carefully assess any fractured clavicle along its whole length, both clinically and radiologically. Various options, from non-operative to operative, have been reported to manage such of these cases. Early bony fixation and soft tissue reconstruction can correct the alignment of clavicle and recover the function of sterno-clavicular and acromio-clavicular- joints promptly.ConclusionFracture osteosynthesis and early soft tissue reconstruction can be regarded as an option treatment for bipolar fracture-dislocation of the clavicle to facilitate prompt treatment and early rehabilitation.     

Coracoclavicular stabilization using a suture anchor technique

Multiple fixation options exist for coracoclavicular stabilization, but many are technically demanding and require hardware removal. In the study reported here, we reviewed a specific fixation technique that includes suture anchors moored in the base of the coracoid process. We retrospectively reviewed 24 consecutive cases of patients who underwent coracoclavicular stabilization with a suture anchor for a type III or type V acromioclavicular (AC) joint separation or a group II, type II or type V distal clavicle fracture. Eighteen of the 22 patients had full strength and painless range of motion (ROM) in the affected extremity by 3 months and at final follow-up (minimum, 24 months; mean, 39 months). Two patients were lost to follow-up. Four patients had early complications likely secondary to documented noncompliance. Two of these 4 patients underwent reoperation with a similar procedure and remained asymptomatic at a minimum follow-up of 15 months. One patient underwent osteophyte and knot excision 7 months after surgery and remained asymptomatic at 30 months. Our results suggest that coracoclavicular stabilization using a suture anchor technique is a safe and reliable method of treating acromioclavicular joint separations and certain distal clavicle fractures in the compliant patient.     

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。     

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。     

Floating clavicle after a high velocity biking accident: A case report of an acromioclavicular dislocation with simultaneous proximal clavicle fracture managed surgically

IntroductionClavicle fractures and acromioclavicular joint dislocations are very common injuries. However, the combination of both, known as “floating clavicle” is extremely rare, with approximately 40 cases reported.Presentation of caseWe report a case of a healthy 51-year-old male who suffered a high-velocity biking accident, with a bipolar clavicle injury (type IV acromioclavicular joint dislocation and proximal clavicle fracture), with concomitant rib fractures and pulmonary contusion. He received early surgical treatment by open reduction and osteosynthesis of the proximal clavicle (distal ulna plate, Protean®) and open reduction and stabilization with a MINAR® implant for the acromioclavicular joint. After an initial one-month immobilization, he started physical therapy. In the 10-month follow-up he presented with a pain-free full range of motion, a good cosmetic result, and radiological consolidation.DiscussionBipolar clavicle injury is a rare clinical entity that encompasses a spectrum of combined clavicle fractures, acromioclavicular or sternoclavicular joint dislocations. They are sustained in a high-energy context, and accompanying injuries must be sought. Diagnosis is made through X-Ray and CT. Despite the lack of clinical guidelines, most authors agree on surgical management of at least one of the injuries, with multiple surgical techniques available. There is an emphasis in surgical treatment of the young and active patient. Conservative treatment is associated with poorer results.ConclusionIt is advisable to have a high index of suspicion for floating clavicle in a high-energy trauma patient, given possible life-threatening injuries, and long-term shoulder sequelae. Surgery should be considered in a young and active patient.     

Coracoclavicular Ligament Reconstruction Using a Semitendinosus Graft for Failed Acromioclavicular Separation Surgery

Although acromioclavicular joint separations are fairly common, the occurrence of high-grade acromioclavicular separations that require surgery is low. Various modifications of the Weaver-Dunn procedure have been popular and fairly successful methods to treat severe acromioclavicular separations, despite the fact that reconstructions have been done a number of ways. We report on the results of a technique for salvaging failed modified Weaver-Dunn reconstructions using a semitendinosus graft through bone tunnels in the distal clavicle and coracoid to reconstruct the coracoclavicular ligament.