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。     

喙锁韧带解剖重建治疗肩锁关节脱位的初步研究

[目的]运用数字化技术测量喙锁韧带中轴长度和倾斜角度,探索解剖重建喙锁韧带治疗肩锁关节脱位的可行性及安全性。[方法]收集36例正常肩锁关节CT扫描的原始数据(DICOM格式)。将数据导入数字骨科图像处理软件(Super Image orthopedics edition 1.2.6 Cybermed Ltd,中国上海),重建出肩锁关节的三维模型,根据现有的喙锁韧带解剖参数在骨面分别标记锥状韧带和斜方韧带的附丽点,测量喙锁韧带中轴长度和倾斜角度并模拟四种喙锁韧带解剖重建方法,分别是双束完全解剖重建、单束近似解剖重建、改良双束完全解剖重建和改良单束近似解剖重建。[结果]锥状韧带和斜方韧带中轴长度分别为(10.42±2.50)mm和(12.35±2.35)mm,锥状韧带与水平面和矢状面所成角分别为(66.98±9.62)°和(30.55±7.37)°;斜方韧带与水平面和矢状面所成角分别为(52.23±11.29)°和(55.51±8.74)°。双束完全解剖重建和单束近似解剖重建的骨皮质突破率分别为91.67%和38.89%。[结论]双束完全解剖重建几乎不可行,单束近似解剖重建仍有较大的骨皮质突破率。改良的双束和单束重建可完全避免锁骨喙突骨隧道突破骨皮质。     

喙锁韧带附着区域的定量解剖学研究

目的对喙锁韧带及其附着位置进行解剖测量, 为解剖重建喙锁韧带治疗肩锁关节脱位提供解剖学相关数据。方法取87具成人尸体双侧肩锁关节标本, 首先逐层解剖出喙锁韧带, 用数显游标卡尺分别测量锥状韧带和斜方韧带在锁骨和喙突附着处的宽度和厚度, 然后在韧带起止点分别切断锥状和斜方韧带, 用美蓝标记韧带在锁骨和喙突表面的附着区域, 最后分别测量韧带附着区域中心距锁骨、喙突各边的距离以及锁骨、喙突对应的长度和宽度。结果本研究标本的锥状和斜方韧带附着中心距锁骨远端的距离分别为(35.7 ± 3.4)mm和(21.8 ± 2.7)mm, 此距离分别占锁骨全长的25.5% ± 0.9%和15.6% ± 1.1%。本研究标本的锥状和斜方韧带附着中心距喙突尖的距离分别为(35.1 ± 3.2)mm和(29.7 ± 2.9)mm, 此距离分别占喙突全长的86.7% ± 1.9%和73.3% ± 2.1%。结论虽然中国人喙锁韧带在锁骨和喙突表面附着的绝对位置个体差异很大, 但是其相对位置与锁骨、喙突长宽的比例是一组相对稳定的数据。     

三重纽扣钢板重建喙锁韧带的解剖及生物力学研究

目的为应用三重固定纽扣钢板重建喙锁韧带治疗肩锁关节脱位提供解剖形态学及生物力学基础。方法对40个肩锁关节的喙锁韧带进行解剖学观测及测量,并对三重固定纽扣钢板重建喙锁韧带和喙锁韧带进行力学测试。结果斜方韧带位于锁骨的中心,锥状韧带位于锁骨稍偏后侧,从锁骨的远端关节面中心到斜方韧带和锥状韧带中心的距离分别为（20.8±0.8）mm和（39.7±0.9）mm。三重固定纽扣钢板重建喙锁韧带较原始喙锁韧带在生物力学性能上占有较大的优势。结论应用三重固定纽扣钢板重建喙锁韧带具有解剖形态学及生物力学基础。     

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。     

喙锁韧带走行方向在肩锁关节脱位治疗中的意义

目的测量喙锁韧带(斜方韧带和锥状韧带)的走行方向,便于术者行肩锁关节脱位手术时重建喙锁韧带。方法 17具(34肩)成人尸体标本,分别标记斜方韧带和锥状韧带于锁骨及喙突止点中心,分别于韧带锁骨止点中心穿克氏针至喙突止点中心,测量克氏针倾斜角度以测量喙锁韧带的走行方向。结果斜方韧带的外展角为(39.39±1.02)°(36.8°~42.0°),后倾角为(6.04±0.63)°(4.8°~7.2°);锥状韧带的外展角为(6.62±0.68)°(5.5°~8.2°),后倾角为(10.99±1.01)°(7.0°~12.0°)。结论研究喙锁韧带走行方向、角度,有利于术者钻孔行喙锁韧带重建时确定骨道的方向。     

双源双能量CT扫描在锁骨远端骨折中的应用研究

目的采用双源双能量CT（dual-energy CT,DECT）扫描，探讨其在合并韧带损伤的锁骨远端骨折中的应用价值。 方法2019年1月至2021年6月，10例锁骨远端骨折患者纳入研究，其中男6例、女4例。平均年龄39.8岁，年龄范围15~67岁。利用DECT技术重建健侧及骨折端锁骨远端下表面斜方韧带及锥状韧带。锁骨远端骨折的类型和数量如下：Neer-craig 5型10例（骨折组），以健侧自身对照重建10例（对照组）。所有DECT韧带特定颜色映射图像均由1名放射科医生和1名骨科医师独立分析。每个重建韧带分为近端、中间和远端三部分，并使用三点量表分别评分（0 =不存在"双能量染色"；1 =部分"双能量染色"；2 =完全"双能量染色"）。 结果重建韧带的总可视化得分平均值为5分或更多，满分6分。骨折组：斜方韧带（5.0±0.1）分，锥状韧带（5.2±0.1）分；对照组：斜方韧带（5.3±0.2）分，锥状韧带（5.7±0.2）分，对斜方韧带及锥状韧带的观察具有高度一致性（范围0.72~0.94）。 结论DECT成像技术可以成为定性显示锁骨远端骨折斜方韧带及锥状韧带完整性，为指导临床分型及治疗提供重要参考。     

喙锁韧带不同重建方法治疗肩锁关节脱位的有限元分析

目的：建立喙锁韧带单束重建、双束解剖重建及双束完全解剖重建有限元模型,比较其位移及受力情况,为喙锁韧带完全解剖重建临床应用提供理论依据。方法：选取1位志愿者,年龄27岁,身高178 cm,体重75 kg,行肩关节CT扫描,运用Mimics17.0、Geomagic studio 2012、UG NX 10.0、Hypermesh14.0、Abaqus 6.14软件建立喙锁韧带单束重建、双束解剖重建及双束完全解剖重建三维有限元模型,各模型分别向前载荷、向后载荷及向上载荷的载荷,记录并比较在主要受力方向上锁骨远端中点的最大位移以及不同载荷情况下重建装置的最大等效应力。结果：施加向前载荷、向后载荷,双束完全解剖重建锁骨远端中点的向前最大位移及向后最大位移最低,分别为7.76 mm和7.27 mm;施加向上载荷,双束解剖重建锁骨远端中点向上最大位移最低,为5.12 mm;施加向前、向后及向上3种不同载荷,双束重建的重建装置最大等效应力均低于单束重建;双束完全解剖重建斜方韧带重建装置最大等效应力较双束解剖重建低,为73.29 MPa,但锥状韧带重建装置的最大等效应力高于双束解剖重建。结论：喙锁韧带双束完全解剖重建能够提高肩锁关节的水平稳定性,降低斜方韧带重建装置的应力,可作为治疗肩锁关节脱位的较好方法。     

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。     

双源CT能谱纯化单能量技术在评估喙锁韧带中的价值

目的探讨双源CT能谱纯化单能量技术对喙锁韧带结构显示的可行性及对韧带显示最佳的能量级。 方法回顾性分析40例双能量CT扫描的单侧肩关节患者影像学资料，采用双源CT"单能+"软件分别获得喙锁韧带40 keV、60 keV、70 keV、80 keV、100 keV 5组单能量图像，并与线性融合（M=0.5）图像对比，分析比较不同能级单能量图像间的CT值及信噪比（signal-to-noise ratio，SNR）、最佳单能量图像与线性融合（M=0.5）图像间的SNR以及总体主观图像质量评分。 结果（1）斜方韧带及锥状韧带在40 keV总体主观图像质量评分均高于其他5组（P均<0.05）。2位观察者间主观图像质量评分一致性较好[Kappa（斜方）：0.822~0.978；Kappa（锥状）：0.905~0.971]。（2）5组单能量图像间的斜方韧带CT值及锥状韧带CT值差异均有统计学意义（P均<0.001），且40 keV>60 keV>70 keV>80 keV>100 keV 。（3）40 keV斜方韧带及锥状韧带图像的SNR均高于其他4组，差异有统计学意义（P均<0.05）；70 keV与80 keV斜方韧带及锥状韧带间SNR值比较差异无统计学意义（P>0.05），余各组间的SNR差异均有统计学意义（P<0.05），且40 keV>60 keV>70 keV>100 keV；与线性融合（M=0.5）图像相比，40 keV新单能量图像斜方韧带及锥状韧带SNR值均较高（P<0.05）。 结论双能量CT的单能纯化技术可清晰显示喙锁韧带形态及走行，且在40 keV时对斜方韧带及锥状韧带的显示最佳。     

Biomechanical study of the ligamentous system of the acromioclavicular joint

The ligamentous structures of the acromioclavicular joint were studied by gross examination and quantitative measurement in twelve human cadaver specimens. Distances between insertions at various extreme positions of the clavicle were studied with the biplane radiographic technique. Ligamentous contributions to joint constraint under displacements were determined by performing load-displacement tests along with sequential sectioning of the ligaments. Twelve modes of joint displacement were examined. The acromioclavicular ligament acted as a primary constraint for posterior displacement of the clavicle and posterior axial rotation. The conoid ligament appeared to be more important than has been previously described. That ligament played a primary role in constraining anterior and superior rotation as well as anterior and superior displacement of the clavicle. The trapezoid ligament contributed less constraint to movement of the clavicle in both the horizontal and the vertical plane except when the clavicle moved in axial compression toward the acromion process. The various contributions of different ligaments to constraint changed not only with the direction of joint displacement but also with the amount of loading and displacement. For many directions of displacement, the acromioclavicular joint contributed a greater amount to constraint at smaller degrees of displacement, while the coracoclavicular ligaments, primarily the conoid ligament, contributed a greater amount of constraint with larger amounts of displacement.     

Ligamentous anatomy of the distal clavicle

We describe the insertional variations of supporting ligaments of the acromioclavicular joint, especially with respect to gender. We analyzed 41 cadaveric clavicles (22 female and 19 male) with attached ligaments. The distance between the insertion of the trapezoid ligament and the distal end of the clavicle was not significantly different between sexes, although that of the conoid ligament and the mean anteroposterior width of the distal clavicle was significantly greater in men. Although there are significant sex-related differences in the insertional distances of the CC ligaments, resection of less than 11.0 mm should not violate the trapezoid ligament and less than 24.0 mm should not violate the conoid ligament in either sex in 98% of the general population. Resection of more than 7.6 mm of the distal clavicle in men and 5.2 mm in women, performed by an arthroscopic approach, may violate the superior acromioclavicular ligament.     

Arthroscopic Suprascapular Nerve Release at the Suprascapular Notch in a Cadaveric Model: An Anatomic Approach

Arthroscopic release of the suprascapular nerve at the suprascapular notch, to our knowledge, has rarely been described. The purpose of this study was to evaluate the feasibility and relevant anatomic landmarks in a cadaveric model that can be identified arthroscopically for reliable and reproducible arthroscopic release of the superior transverse scapular (STS) ligament. In 8 fresh-frozen cadaveric shoulders, arthroscopic release of the STS ligament was performed. The acromioclavicular joint is first identified while viewing through a posterior subacromial portal. The distal clavicle is then followed medially until the most lateral portion of the coracoclavicular (CC) ligaments (trapezoid ligament) is identified. The most medial margin of the CC ligaments (conoid ligament) is identified, and the trapezoid and conoid ligaments are dissected and identified individually. The conoid ligament is followed inferiorly and medially to the base of the coracoid. At the base of the coracoid, the confluence of the trapezoid and conoid ligaments (CC) and the STS ligament is identified. The STS ligament can be identified coursing horizontally across the field of view. The STS ligament may be incised by use of dissecting scissors through a lateral, accessory lateral, or accessory posterior portal, releasing the suprascapular nerve.     

The relation of the coracoclavicular ligament insertion to the acromioclavicular joint: a cadaver study of relevance to lateral clavicle resection

Resection of the lateral end of the clavicle is a common procedure for arthrosis of the acromioclavicular joint (AC-joint). However, no anatomical data on the distance between the insertions of the coracoclavicular ligaments and the AC-joint have been reported. In 36 cadaver shoulders (18 male), we studied the relation between the AC-joint and the insertions of the joint capsule, trapezoid and conoid ligaments. The distance from the AC-joint to the medial end of its capsule was, on average, 0.7 cm (0.4-0.9) cm in women and 0.8 (0.4-1.2) cm in men. In women, the trapezoid ligament began, on average, at 0.9 (0.4-1.6) cm and ended at 2.4 (2.0-2.8) cm and in men, it began at 1.1 (0.8-1.6) cm and ended at 2.9 (2.1-3.8) cm medial to the AC joint. The corresponding figures for the conoid ligament were 2.6 (2.0-3.7) cm and 4.7 (3.9-6.2) cm. A resection of 1 cm of the lateral clavicle detaches 8%, a resection of 2 cm 60% and a resection of 2.5 cm 90% of the trapezoid ligament. We recommend a maximum resection of 1 cm of the lateral clavicle because a resection of 2 cm or more may cause postoperative AC-joint instability and related pain.     

The relation of the coracoclavicular ligament insertion to the acromioclavicular jointA cadaver study of relevance to lateral clavicle resection

Resection of the lateral end of the clavicle is a common procedure for arthrosis of the acromioclavicular joint (AC-joint). However, no anatomical data on the distance between the insertions of the coracoclavicular ligaments and the AC-joint have been reported. In 36 cadaver shoulders (18 male), we studied the relation between the AC-joint and the insertions of the joint capsule, trapezoid and conoid ligaments. The distance from the AC-joint to the medial end of its capsule was, on average, 0.7 cm (0.4-0.9) cm in women and 0.8 (0.4-1.2) cm in men. In women, the trapezoid ligament began, on average, at 0.9 (0.4-1.6) cm and ended at 2.4 (2.0-2.8) cm and in men, it began at 1.1 (0.8-1.6) cm and ended at 2.9 (2.1-3.8) cm medial to the AC joint. The corresponding figures for the conoid ligament were 2.6 (2.0-3.7) cm and 4.7 (3.9-6.2) cm. A resection of 1 cm of the lateral clavicle detaches 8%, a resection of 2 cm 60% and a resection of 2.5 cm 90% of the trapezoid ligament. We recommend a maximum resection of 1 cm of the lateral clavicle because a resection of 2 cm or more may cause postoperative AC-joint instability and related pain.