Minimalinvasive Akromioklavikulargelenkrekonstruktion (MINAR)

Objective

Reduction and retention of an acromioclavicular (AC) joint dislocation with a button/suture augmentation cerclage (Flip tack, Karl Storz, Tuttlingen, Germany).

Indications

Dislocation of the AC joint (Rockwood III and V). Chronic instabilities in combination with autogenous replacement of the coracoclavicular ligaments. Lateral clavicular fracture with rupture of the coracoclavicular ligaments.

Contraindications

Patients in poor general condition. Local soft-tissue infection. Low-degree dislocation of AC joint (Rockwood I und II). Fracture of the clavicular shaft. Chronic instabilities without ligament replacement.

Surgical Technique

The coracoid process is exposed by a 3 cm long skin incision. A hole is drilled through the coracoid process with the help of a specific aiming device. The suture cerclage is connected to two buttons. One of the buttons is then pushed through the coracoid process. The button is flipped and the suture thereby fixed to the coracoid process. The other anchor is pulled through a hole in the clavicle and the cerclage is secured with a surgical knot after reduction of the AC joint.

Postoperative Management

Application of an abduction splint for 4 weeks (15°).

Results

23 patients with an acute luxation of the AC joint were operated with a minimally invasive coracoclavicular cerclage (five patients with Rockwood type III and 18 patients with Rockwood type V). Mean operative time was 28.6 min. Perior postoperative complications such as nerve and vascular injuries, thoracic injuries, infection, thrombosis, and embolism did not occur. The mean Constant Score was 94.1 points (73–100 points) after a mean of 23.3 months (18–28 months). In two cases, a slight loss of reposition of less than half of the clavicle width in comparison with the contralateral side was observed.     

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.     

Die laterale Klavikulafraktur

Objective

Reposition and fixation of unstable distal clavicle fractures with a low profile locking plate (Acumed, Hempshire, UK) in conjunction with a button/suture augmentation cerclage (DogBone/FibreTape, Arthrex, Naples, FL, USA).

Indications

Unstable fractures of the distal clavicle (Jäger and Breitner IIA) in adults. Unstable fractures of the distal clavicle (Jäger and Breitner IV) in children. Distal clavicle fractures (Jäger and Breitner I, IIB or III) with marked dislocation, injury of nerves and vessels, or high functional demand.

Contraindications

Patients in poor general condition. Fractures of the distal clavicle (Jäger and Breitner I, IIB or III) without marked dislocation or vertical instability. Local soft-tissue infection.

Surgical technique

Combination procedure: Initially the lateral part of the clavicle is exposed by a 4 cm skin incision. After reduction of the fracture, stabilization is performed with a low profile locking distal clavicle plate. Using a special guiding device, a transclavicular–transcoracoidal hole is drilled under arthroscopic view. Additional vertical stabilization is arthroscopically achieved by shuttling the DogBone/FibreTape cerclage from the lateral portal cranially through the clavicular plate. The two ends of the FibreTape cerclage are brought cranially via adjacent holes of the locking plate while the DogBone button is placed under the coracoid process. Thus, plate bridging is achieved. Finally reduction is performed and the cerclage is secured by surgical knotting.

Postoperative management

Use of an arm sling for 6 weeks.

Results

Due to the fact that the described technique is a relatively new procedure, long-term results are lacking. In the short term, patients postoperatively report high subjective satisfaction without persistent pain.     

Analysis of risk factors for loss of reduction after acromioclavicular joint dislocation treated with the suture-button

BackgroundThe most commonly reported complication after acromioclavicular (AC) joint dislocation treated with the Suture-button is loss of reduction. Loss of reduction is a major factor influencing the patient's joint function and subjective satisfaction. The objective of this study is to analyze the risk factors causing loss of reduction after AC joint dislocation treated with the Suture-button.MethodsOne hundred and thirty patients with AC joint dislocation who were surgically treated the Suture-button in our hospital from February 2009 to February 2015, were recorded their age, sex, BMI, time from injury to surgery, Rockwood's classification, with or without osteoporosis, double or triple button technique, position of the clavicle tunnel, tunnel diameter, coracoid button position, alignment of the button, acromioclavicular ligament repair or not, different methods of postoperative limb immobilization, and so on. Mean comparisons or chi-square test was used for univariate analysis of the above factors, and then multivariate logistic regression analysis was performed to predict risk factors.ResultsReduction was lost in 23.1% of the patients. Univariate analysis showed that button alignment, double or triple button technique, coracoid button position, position of the clavicle tunnel, acromioclavicular ligament repair or not and osteoporosis had statistically significant association with loss of reduction for AC joint (P = 0.031, 0.034, 0.000, 0.042, 0.047 and 0.000 respectively). Multivariate logistic regression analysis demonstrated that osteoporosis (P = 0.003), position of the clavicle tunnel (P = 0.032) and coracoid button position (P < 0.001) were the risk factors that significantly associated with the loss of reduction after AC joint dislocation treated with the Suture-button.ConclusionsClavicle tunnel location using relative ratio method, accurate placement of button plate under coracoid process (inside or outside deviation <20°), various reinforcement operations for patients with osteoporosis are important factors in preventing loss of reduction.     

Arthroskopisch assistierte Stabilisierung bei akuter und chronischer Akromioklavikulargelenksprengung

Objective

The surgical procedure aims at anatomic reduction and stabilization of the acromioclavicular joint in vertical and horizontal planes for acute separations using a trans-clavicular and trans-coracoidal suture tape fixation with additional acromioclavicular joint augmentation with a PDS cord cerclage. For chronic instability adding a tendon graft is essential for sustainable stability.

Indications

Acute und chronic acromioclavicular joint separations type Rockwood III–VI. Recurrent AC-joint instability with intact coracoid process (with tendon graft).

Contraindications

Acromioclavicular joint separations type Rockwood I–II. Asymptomatic chronic AC-separations type Rockwood III–IV. Fracture close to base of coracoid process General contraindications for (elective) surgery.

Surgical technique

Vertical reconstruction of the coraco-clavicular ligaments using a drill-guide for trans-clavicular and trans-coracoidal tunnel placement for high-strength suture tapes over titanium buttons. Additional stabilization of the AC-joint with a transosseus figure of 8 PDS suture cord cerclage.

Postoperative management

Postoperatively the arm is put in a regular sling for 6 weeks. Free active range of motion of wrist and elbow. Shoulder range of motion is limited to 30° of flexion and abduction and 80° internal and 0° external rotation for 2 weeks. Extended to active-assisted 45° flexion and abduction in weeks 3 and 4 and advanced to 60° flexion/abduction and free internal/external rotation in weeks 5 and 6. Range of motion is unlimited from week 7. Full daily life activities after 3 months, high-impact sports after 5–6 months postoperatively.

Results

The presented surgical technique reliably stabilizes the acromioclavicular joint. It’s biomechanical properties with only the single-tunnel coracoclavicular suture tapes is on the level of the native vertical stability, which can be additionally improved for better horizontal stability with the cerclage over the AC-joint.     

The stabilizing effect of various implants on the torn acromioclavicular joint. A biomechanical study

A biomechanical in vitro test was performed to determine the stabilizing effect of various implants for the surgical treatment of the torn acromioclavicular joint. In a specially designed testing device, plastic and cadaver specimens of the shoulder girdle were stressed in various ways. Different dislocations between the acromion and the clavicle and between the clavicle and the coracoid were determined, as well as the stiffness of the implants. A convenient stabilizing effect combined with less rigid fixation to secure the newly treated AC joint was provided by K-wire fixation with cerclage. Interfering shear and bending stresses could be avoided with this method, while the other implants showed various disadvantages. From a biomechanical point of view, a carbon-fiber ligament replacement provides sufficient stability in cases of chronic acromioclavicular separation.     

喙突钢板位置对应用Triple Endobutton技术治疗肩锁关节脱位疗效的影响

目的探讨应用Triple Endobutton技术治疗肩锁关节脱位时喙突钢板位置对疗效的影响。 方法将2010年1月至2015年12月温州医科大学附属第二医院收治67例患者按术后X线中喙突钢板位置分为偏外侧组（n=19）、中央组（n=27）、偏内侧组（n=21）。记录患者一般资料及术后并发症的发生情况,采用Constant评分、视觉模拟评分（visual analogue scale,VAS）及肩关节简单评分（simple shoulder test,SST）综合评估肩关节功能。 结果三组患者总并发症发生率为41.8%（28/67）。三组间并发症发生率（12/19 vs. 6/27 vs. 10/21,P=0.017）及复位丢失率（8/19 vs. 2/27 vs. 5/21,P=0.020）差异有统计学意义,偏外侧组患者并发症发生率显著高于中央组（P <0.01）。三组术后Constant评分分别为（91.2±4.2）分、（94.3±3.6）分、（93.9±4.2）分,中央组及偏内侧组评分高于偏外侧组,差异有统计学意义（P <0.05）,但三组间VAS评分（P=0.742）及SST评分（P=0.258）差异无统计学意义。 结论应用Triple Endobutton技术治疗急性肩锁关节脱位的过程中,喙突骨隧道的位置与临床疗效关系密切,中央型骨隧道并发症少,效果显著。术中透视若发现喙突骨隧道偏移,尤其是向外侧偏移,应立即予以纠正。     

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。     

Management of acute unstable distal clavicle fracture with a modified coracoclavicular stabilization technique using a bidirectional coracoclavicular loop system

Background

Fracture of the distal clavicle is not uncommon. Despite the vast literature available for the management of this fracture, there is no consensus regarding the gold standard treatment for this fracture.

Purpose

To assess the clinical and radiographic outcomes and complications of acute unstable distal clavicle fracture when treated by a modified coracoclavicular stabilization technique using a bidirectional coracoclavicular loop system.

Methods

Thirty-nine patients (32 males, 7 females) with acute unstable distal clavicle fractures treated by modified coracoclavicular stabilization using the surgical technique of bidirectional coracoclavicular (CC) loops seated behind the coracoacromial (CA) ligament were retrospectively reviewed. Mean follow-up time was 35.7 months (range 24–47 months). The outcomes measured included union rate, union time, CC distances when compared to the patients’ uninjured shoulders, and the Constant and ASES shoulder scores, which were evaluated 6 months after surgery.

Results

All fractures displayed clinical union within 13 weeks postoperatively. The mean union time was 9.2 weeks (range 7–13 weeks). At the time of union, the CC distances on the affected shoulders were on average 0.9 mm (range 0–1.6 mm) longer than the unaffected shoulders. At 6 months after surgery, the Constant and ASES scores were on average 93.4 (72–100) and 91.5 (75–100), respectively. No complications related to the fixation loops, musculocutaneous nerve injuries, or fractures of coracoid or clavicle were recorded. One case of surgical wound dehiscence was observed due to superficial infection. Enlargement of the clavicle drill hole without migration of the buttons was observed in 9 out of 16 cases at a follow-up time of at least 30 months after the original operation.

Conclusions

Modified CC stabilization using bidirectional CC loops seated behind the CA ligament is a simple surgical technique that naturally restores stability to the distal clavicle fracture. It also produces predictable outcomes, a high union rate, good to excellent shoulder function, and a low complication rate. The buttons and suture loops were routinely removed in a second operation in order to prevent late stress fracture of the clavicle.

     

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。     

Clinical and radiographical results after double flip button stabilization of acute grade III and IV acromioclavicular joint separations

Introduction

Persistent horizontal instability after acute acromioclavicular (AC) joint separation may provoke unsatisfactory results of conservative treatment. Hypothesis: the arthroscopically assisted double flip button stabilization of acute horizontally unstable grade III and IV AC joint disruptions results in full functional restoration and stable radiological reposition.

Materials

21 patients treated for an acute grade III or IV AC joint separation were enrolled. Clinical assessment at least 2-year postoperative included the constant score (CS) and the simple shoulder test. A panorama stress view, bilateral axial view and an AC view were obtained for radiographic evaluation.

Results

19 individuals (mean 37 years; 17 men) with 16 Rockwood type III and 3 type IV injuries were available for examination 24–51 months postoperatively. The mean CS was 90.2 points (SD 6.5) with no statistically significant difference between CS and age-adjusted normative values. The mean Simple Shoulder Test scored 11.5 points (range 8–12). Loss of reduction of more than 2 mm in the coronal plane stress views was present in 6 patients (32 %) with no associated loss of functional outcome. Two of four reported complications in four patients were treated surgically (one open revision with graft augmentation for coracoid implant break out, one arthroscopic capsular release for persistent glenohumeral stiffness).

Conclusion

Arthroscopically assisted double flip button stabilization for acute grade III and IV AC joint separation restores fully horizontal stability and age-expected shoulder function, resulting in high patient satisfaction, despite a loss of reduction observed radiographically in approximately one-third of patients.

Level of evidence

IV.     

Arthroscopic Anatomical Acromioclavicular Joint Reconstruction using a Button Device and a Semitendinosus Graft

ObjectiveTo report a new technique for anatomical acromioclavicular (AC) joint reconstruction.MethodsIn order to minimize such complications, the authors describe a new anatomical and biological AC joint repair. This technique aims to provide greater stability by using two anatomically placed clavicular tunnels and a combined construct with a double endobutton cortical fixation for primary stabilization, and to be biologically advantageous by using an autologous semitendinosus (ST) tendon graft. Additionally, the coracoclavicular ligament reconstruction is complemented with an AC joint cerclage and capsular reinforcement, which will protect the biological construction in its initial stage of healing.ResultsThis technique provides adequate primary and secondary biomechanical stability by passing both a semitendinosus autogenous graft and a double endobutton device, through anatomically placed and small diameter clavicle holes, without the need for coracoid drilling. Our technique showed encouraging results regarding pain resolution, range of motion, and function. At final follow‐up we experienced excellent results with average pain score of 1.6, and average ROM of 159° of forward flexion, 160° of abduction, 68° of external rotation, and internal rotation level at T11. Postoperative function also showed great improvements with average ASES of 85 points, an average Constant Score of 87 and a Subjective Shoulder Value of 89 points. This technique also achieved perfectly acceptable radiographic results, with an average coracoclavicular distance increase of 0.8 mm. Regarding complications, our sample showed one case of AC join subluxation, two cases of internal saphenous nerve injury, and two partial graft tears at the suture‐button interface, with none of these requiring surgical revision.ConclusionThis technique is advantageous in treatment of acromioclavicular joint dislocation and can be performed in both the subacute and chronic setting.     

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.     

Suture Rupture in Acromioclavicular Joint Dislocations Treated With Flip Buttons

Acute acromioclavicular joint dislocations (ACDs) may be treated arthroscopically with flip buttons. This extra-articular fixation is easy to implant and is well tolerated. Between 2007 and 2009, 20 ACD patients (2 women and 18 men; mean age, 32 years) had surgery by the arthroscopic TightRope technique (Arthrex, Naples, FL). The main complication of this technique that has been reported is the partial loss of reduction at follow-up due to clavicular osteolysis under the superior flip button. We describe 4 cases with loss of reduction due to rupture of the sutures running across the buttons: 2 women with joint hyperlaxity and acute Rockwood grade IV ACD and 2 men, heavy manual workers, with joint hyperlaxity and acute Rockwood grade IV ACD. The use of flip buttons might not be indicated in patients with joint hyperlaxity because they are able to obtain immediate stability only on the vertical plane and not on the horizontal plane. Anteroposterior movements of the acromioclavicular joint might rub the suture against the bone tunnels leading to wear and cutting.     

Innovative use of single-incision internal fixation of distal clavicle fractures augmented with coracoclavicular stabilisation

Introduction

The management of displaced fractures of the distal clavicle remains controversial, particularly in younger patients where there is no consensus as to which surgical intervention is best. Each surgical method has unique surgical complications and rates of persistent pain and post-traumatic arthritis. We report an innovative surgical technique using a plate fixation augmented with minimally invasive tension slide coracoclavicular fixation using a cortical tenodesis button (8.5 mm).

Methods

A single-surgeon series, comprising of eleven cases, underwent retrospective review. A low-profile pre-contoured stainless steel plate that combines locking and non-locking options was used. Secondary fixation to the coracoid, through the plate, was achieved under fluoroscopic guidance eliminating the need for arthroscopy or exposure of the coracoid. An 8.5-mm cortical button loaded with a single FiberTape is inserted with fluoroscopic navigation, flipped under the coracoid and fixed to the plate. Patients followed a standardised rehabilitation protocol and clinical review assessing time to union, complications and Oxford Shoulder Scores.

Results

The mean age of the patients was 40 years, 82% male. The majority were day-case admissions with a mean follow-up of 18 months. Although a single patient requested plate removal due to lateral prominance, there were no revisions for implant failure and no surgical site infections or neurovascular injuries. All patients were reviewed at a minimum of 17 weeks and were progressing to union. Mean Oxford Shoulder Score was 43 (28–48, SD 6.5).

Conclusion

We consider this technique ideal for treating Neer type II distal clavicle fractures or fractures that have poor bone quality laterally, in which it can be difficult to achieve adequate screw fixation. The technique benefits from smaller tunnel diameter (3.7-mm spade-tip drill) and button length (8.5 mm). The procedure has a short learning curve and is both safe and time efficient.

Level of evidence

IV.

     

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.     

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。     

The operative treatment of fresh ruptures of the acromioclavicular joint (Tossy III)

Summary We give a preliminary report of ten patients with fresh dislocations of the acromioclavicular joint (Tossy III). All ten were operated with suture of the torn ligaments and indirect fixation of the acromioclavicular joint with a monocerclage wire passed around the coracoid process and the clavicle. Removal of metal was done 8 weeks later. None of the wires broke, and there were no problems with wound healing. Control X-rays under stress revealed stable acromioclavicular joints in all cases.     

Injuries of the acromio- and sternoclavicular joint--surgical or conservative treatment?

At the acromioclavicular (AC) joint we distinguish between horizontal instability caused by damage to the AC ligament from vertical instability caused by damage to the coracoclavicular liagments. The most common mechanism of injury is direct force resulting from a fall onto the point of the shoulder. The injury is classified according to the amount of damage brought about by a given force. Horizontal and vertical instability have to be evaluated by special radiographic views. Types I and II are treated by a sling worn for a few days and the application of ice bags. In type III injuries the patient's age, job and acitve pursuits determine whether or not surgery is indicated. In type IV-VI injuries we always perform the operation. We use a resorbable cerclage between the clavicle and the coracoid process and suture all torn ligaments. In the sternoclavicular joint too, the ligamentous stability is of the utmost importance. The sternoclavicular ligament limits the ante- and retroversion of the clavicle, while the costoclavicular ligament limits the upward movement. The direction of subluxation or luxation has to be evaluated by means of an oblique view X-ray with a cephalic tilt of the tube through 40 degrees or by a computed tomogram. In the case of an acute injury closed reduction should always be attempted. Open recuction should only be performed in cases of persistent posterior luxation, because of the numerous complications that are possible in such cases.