改良Weaver-Dunn技术治疗急性肩锁关节脱位

目的　探讨改良 Weaver- Dunn技术在治疗急性肩锁关节脱位中的应用价值。方法　 1993年 1月～1998年 12月 ,对 18例急性肩锁关节脱位采用改良 Weaver- Dunn技术 ,另 17例采用肩锁关节张力带内固定术治疗 ,术后随访 12～ 36个月。采用宾西法尼亚大学肩关节功能评分标准 ,对比研究改良 Weaver- Dunn技术在治疗急性肩锁关节脱位中的应用效果。结果　采用改良 Weaver- Dunn技术较采用肩锁关节张力带内固定术后患者近期肩关节功能恢复快 ;术后 12、2 4和 36个月 ,采用改良 Weaver- Dunn技术治疗的结果评分分别为 (189.7± 6 .7)分、(193.7± 3.6 )分和(194 .7± 3.4 )分 ,采用肩锁关节张力带内固定的治疗结果评分分别为 (16 7.3± 7.80 )分、(170 .2± 6 .3)分和 (16 5 .6±5 .9)分。统计学处理两组之间具有统计学意义 (P<0 .0 5 )。结论　与肩锁关节张力带内固定比较 ,改良 Weaver- Dunn技术是一种治疗急性肩锁关节脱位较理想的方法。     

Acromioclavicular reconstruction using autogenous semitendinosus tendon graft: results of revision surgery in chronic cases

Revision surgery of acromioclavicular dislocation is challenging owing to the altered anatomic relationships and the lack of stabilizing structures. In this study, an autogenous semitendinosus tendon graft was used for revision acromioclavicular stabilization, aiming at anatomic coracoclavicular reconstruction, as these patients had previously undergone a Weaver-Dunn procedure, which failed. Twelve patients were followed up clinically and radiographically for a mean of 49.5 months. The primary diagnosis was acromioclavicular joint dislocation Rockwood type III in 6, type IV in 4, and type V in 2 cases. At follow-up, the mean Constant score averaged 76.4 points. Pain relief was statistically significant (P < .01). Radiologic coracoclavicular distance and posterior displacement of the lateral clavicle in the Rockwood type IV cases decreased significantly (P < .01). We conclude that with this new technique of autogenous semitendinosus tendon graft replicating the anatomic ligamentous properties, good to excellent results can be achieved in revision cases of acromioclavicular reconstruction.     

Using suture anchors for coracoclavicular fixation in treatment of complete acromioclavicular separation

For the repair of acromioclavicular separations, we describe a new method of securing the clavicle to the coracoid process using suture anchors. We have repaired 11 consecutive complete acromioclavicular separations in this manner with very good results. We find this to be an easy and reproducible method of anatomical fixation.     

The use of a hook-plate in the management of acromioclavicular injuries. Report of ten cases

A hook-plate is a clavicular small fragment AO plate with a hook engaging below the acromion. It is primarily used to secure the ligament repair in the treatment of displaced acromioclavicular joint dislocations. We have used the hook-plate in conjunction with a Weaver-Dunn procedure to secure the repair in seven patients. In another three we used this plate to reduce and stabilize distal clavicular fractures. Satisfactory results were obtained in all patients; the deformity disappeared, full pain-free shoulder movement was regained with no motor weakness, with a mean follow-up of 11 months (6-25 months). Our patients returned early to work and sports activities (mean period of three months). The three clavicular fractures healed. One patient developed a superficial would infection, which responded to antibiotics and would dressing. None of our patients required removal of the implant. The hook-plate appears to be a useful device for acromioclavicular trauma.     

A Salvage Procedure for Failed Weaver-Dunn Reconstruction

THE PROBLEM: The failure rate after surgical acromioclavicular (AC) joint stabilization is of up to 10%. For revision, several techniques including modifications of the Weaver-Dunn procedure have been suggested. However, patients with failure of such revision techniques represent a special challenge due to the altered anatomic relationships and the lack of stabilizing structures. THE SOLUTION: In this respect, a case of several failed AC joint reconstructions is reported in which a doubled semitendinosus graft was used. The use of either biological autograft or artificial material has been suggested in the literature. However, especially the use of an autograft or allograft tendon has been supported by biomechanical studies. SURGICAL TECHNIQUE: A semitendinosus graft was harvested, passed through a clavicular and a coracoid tunnel, and subsequently doubled around the medial clavicle and the medial coracoid hook. A second pair of tunnels in the distal part of the clavicle and the coracoid was used for tying a 2-mm Fiber-Wire (Arthrex Inc.) cerclage. Then, the tendon graft was sutured beyond itself with # 2 Ethibond (Ethicon Inc., Johnson & Johnson). Consecutively, the deltotrapezial fascia was doubled and closed up with inverted # 1 sutures. After skin closure the left arm was immobilized in a sling. RESULT: 12 months after surgery, the patient was free of pain, presenting with a Constant Score of 87/100 and a Neer Score of 94/100.     

Das Akromioklavikulargelenk

Acute or chronic instability and osteoarthritis of the acromioclavicular (ac) joint may cause significant impairment of the shoulder. In this continuing education report, the pathomorphology of acute ac dislocations is described based on the Rockwood classification. Decision making on conservative or surgical treatment is discussed. Surgical techniques are presented as acromioclavicular or coracoclavicular procedures. Persistent complaints may warrant additional surgical therapy after conservative treatment as well as after primary surgical treatment. In these cases, residual instability must be addressed. A modified Weaver-Dunn procedure is presented in detail. In any patient with shoulder pain, osteoarthritis of the ac joint has to be taken into consideration. Resection of the lateral clavicle has proved to be effective in these patients.     

The acromioclavicular joint

Acute or chronic instability and osteoarthritis of the acromioclavicular (ac) joint may cause significant impairment of the shoulder. In this continuing education report, the pathomorphology of acute ac dislocations is described based on the Rockwood classification. Decision making on conservative or surgical treatment is discussed. Surgical techniques are presented as acromioclavicular or coracoclavicular procedures. Persistent complaints may warrant additional surgical therapy after conservative treatment as well as after primary surgical treatment. In these cases, residual instability must be addressed. A modified Weaver-Dunn procedure is presented in detail. In any patient with shoulder pain, osteoarthritis of the ac joint has to be taken into consideration. Resection of the lateral clavicle has proved to be effective in these patients.     

Chronic acromioclavicular separation: the medium term results of coracoclavicular ligament reconstruction using braided polyester prosthetic ligament

In this series, we treated chronic acromioclavicular disruption with an artificial coraco-clavicular ligament made from braided polyester (The Nottingham Surgilig). The ligament has a loop at each end and is passed around the coracoid process, threaded through itself, then passed around the posterior aspect of the clavicle and finally anchored to it with a bone screw. Eleven men with an average age of 39 underwent this procedure. Three patients had previously been operated on using the Weaver-Dunn procedure which had failed. All eleven patients have been reassessed clinically and radiographically at an average of 55 months. Using the Imatani evaluation score, 10 patients achieved a good/excellent result with the mean Constant score being 92. One patient had fracture of the base of the coracoid after heavy lifting in the early postoperative period which resulted in a poor outcome. Two patients needed an additional operation. In one the lateral end of the clavicle was excised together with removal of the fixation screw, and in the other a subacromial decompression was carried out. The Nottingham Surgilig is a useful alternative for the treatment of chronic acromioclavicular separation, especially in revision reconstruction when the coracoacromial ligament is no longer available.     

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.     

K-wire Arthrodesis and Coracoclavicular Augmentation of Complete Acromioclavicular Separations: Functional and Subjective Results

Abstract Background: In recent years, there has been a trend from operative to conservative management of complete acromioclavicular separations. Despite this, surgical treatment is still recommended to manual workers and athletes, who account for a large part of the patients. The objective of this study was to evaluate the functional outcome of type III separations according to Tossy managed by temporary arthrodesis of the acromioclavicular joint combined with coracoclavicular augmentation. Special attention was paid to sport exercising patients. Patients and Methods: In this study, 32 patients (mean age 39 years) with a complete acromioclavicular separation were investigated. All of them underwent a surgical treatment managed by temporary acromioclavicular arthrodesis with two parallel k-wires and augmentation of the coracoclavicular ligaments with a biodegradable cord (PDS). Functional outcome was assessed after an average follow-up of 36 months by using the Constant-Murley-, Neer- and DASH-score. Additionally, incidence of complications and subjective results were observed. Results: Evaluation of the data, obtained from the scores, revealed an excellent result for the Constant-Murley- and DASH-score for 84% of the patients. Regarding the Neer-score, 78% had an excellent outcome. Eighty-four percent of the patients assessed revealed an excellent to fair subjective result. Cosmetic reasons were most frequently the cause for discontentedness. Minor complications occurred in three patients without severe sequelae. All patients returned back to former working and sport activity level. Conclusion: Surgical treatment of complete acromioclavicular separations by temporary arthrodesis with two k-wires and coracoclavicualar PDS-augmentation results in good to excellent function. It is associated with a low complication rate and a high patient contentedness. Particularly for athletes in non-contact sports this surgical technique can still be recommended. Tim T. L?gters, Daniel Briem are contributed equally and therefore share first authorship     

Minimalinvasive Schultereckgelenkstabilisierung mit freiem Sehnentransplantat

Revision surgery following unsuccessful acromioclavicular (AC) joint stabilization and chronic joint instability presents a great challenge in orthopedics. In those cases, sufficient healing of the coracoclavicular (CC) ligaments cannot be expected. Different kinds of procedures are described for the operative treatment of chronic AC joint instability that can be divided into anatomic and non-anatomic techniques. The basic idea is to provide stability and a biological basis for the ligamentization process of the CC ligaments. The anatomic, minimally invasive operation techniques using TightRope? or similar pulley systems in combination with a free tendon autograft have turned to a widely accepted and used treatment for chronic acromioclavicular (AC) joint separations.     

Acromioclavicular reconstructions with hamstring tendon grafts: a comparative biomechanical study

The surgical treatment of chronic acromioclavicular injuries remains controversial. There is increasing use of autogenous tendon grafts to perform these reconstructions. This study examined the mechanical properties of differing configurations of these grafts. Mechanical testing of acromioclavicular joint reconstructions was performed with a screw and soft tissue washer for tendon fixation, a simple loop of tendon tied to itself, and a bio-interference screw for tendon fixation, with and without a loop of nonabsorbable suture for reinforcement. The bio-interference screw fixation, with reinforcement by a loop of nonabsorbable suture, gave the highest load to failure among the group (502N +/- 177), which was not significantly different from the intact ligaments (705 N +/- 132), although it was significantly less stiff than the intact group (57.2 N/mm +/- 12.6 and 109.7 N/mm +/- 32.6, respectively). All other reconstructions had an ultimate load and stiffness which were significantly less than that of the intact specimens.     

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.     

Treatment of complete acromioclavicular separations with a modified Weaver and Dunn technique

The purpose of this article is to describe the indications, operative technique, and postoperative rehabilitation protocol for treatment of complete acromioclavicular separations. A modified Weaver and Dunn technique is described, with a detailed harvesting procedure of the coracoacromial ligament, along with a wafer of bone for anatomical reconstruction of the coracoclavicular ligaments. A suture anchor is used to provide temporary stability to the acromioclavicular joint while the transferred coracoacromial ligament heals in the new position.     

Type III acromioclavicular separation: rationale for anatomical reconstruction

Treatment of acute type III acromioclavicular separation is controversial. In some patients, nonoperative treatment is associated with pain, weakness, and stiffness. Many acromioclavicular joint reconstructions are associated with complications and results not substantially better than those of nonoperative treatment. Use of autogenous free tendon graft to anatomically reconstruct the acromioclavicular and coracoclavicular ligaments offers several advantages over other surgical techniques. These advantages include improved biomechanical properties, no foreign body implantation, biological fixation, anatomical reconstruction, and early rehabilitation.     

Alte Akromioklavikulargelenkverletzungen

In old injuries of the acromioclavicular (AC) joint the extent of damage to the coracoclavicular ligaments, the AC joint capsule with its strengthening ligaments and in particular the deltotrapezius fascia which is responsible for horizontal stability play an important role. Previously there was no classification of old AC joint injuries. In order to work out criteria for therapy decisions prospective clinical, radiological and sonographic data on old AC injuries were compiled in a standardized way, evaluated and divided into three types A, B and C with four defined subtypes B1, B2, C1 and C2. Old injuries of type A seem to be suitable for treatment by the Weaver-Dunn method but for all other types an additional temporary retention of the AC joint in combination with reconstruction of the deltotrapezius fascia and sometimes ligamentoplastic measures are necessary.     

Stabilization of the injured shoulder joint with PDS cord]

A successful treatment of the acromioclavicular separation is the repair of the acromioclavicular and coracoclavicular (CC-)ligaments and a stable reduction of the acromioclavicular (AC-)joint. To avoid dangerous breakage and migration of the K-wire an abduction humeral splint is necessary immobilizing the injured shoulder for 5-6 weeks. In the years 1987-1989 40 patients suffering AC-separation were treated (34 Tossy III separations, 4 Tossy II separations, 2 Tossy I separations). In these cases a stable reduction was achieved by a transarticular K-wire fixation and a combination of AC- and CC-fixation by loops. In 1987 wire loop was used. In 1988 a combination of wire and Polydioxanon (PDS) loops was used. The PDS-loop, a slowly resorbable suture material, fixed the CC-ligament. In 1989 the AC-joint was stabilized by a PDS-loop as well. The examination of 31 patients 6-24 months after the operation showed good clinical results no matter whether PDS-loops or wire loops were used. The advantage of the transarticular K-wire fixation in combination with PDS-loops was the easy removal, which could be done in mostly of the cases as an outpatient procedure. An operation of the AC-Tossy III separation on patients beyond their 4. decade should be well considered. A long time of treatment, remaining pain and a limitation of shoulder movement must be expected.     

Post-traumatic acromioclavicular instability reconstruction with coracoacromial ligament and conjoined tendon: A preliminary report

BackgroundMany surgical techniques have been proposed to treat acromioclavicular (AC) injuries; however, anatomic coracoclavicular (CC) reconstructions with local tissue grafts have not been reported in previous studies. The aim of this study was to investigate early outcomes of this innovative technique.MethodsBetween 2004 and 2011, 15 patients with post-traumatic AC instability underwent anatomic reconstructions by two surgeons at our institution. Nine patients were treated with local tissue grafts, and these included six patients who underwent double-bundle reconstructions and three who underwent single-bundle reconstructions. The remaining six patients were treated with free tendon grafts. The clinical outcomes of the Constant scores and the radiographic results of the CC distance were further analyzed.ResultsIn patients who underwent reconstructions with local tissue grafts, those treated with double-bundle and selective-bundle reconstructions had an average postoperative Constant score of 89.0 ± 11.5 and 71.7 ± 38.4, respectively. In patients who underwent reconstructions with free tendon grafts, the average score was 73.0 ± 29.4. There was no statistically significant difference among the three reconstruction procedures. Only one patient showed residual AC separation on plain-film radiography.ConclusionThis innovative technique provided clinical and radiographic results that were comparable to those achieved with free tendon grafts. This procedure can be an alternative surgical option for treating AC joint instability.     

Die operative Behandlung der Akromioklavikulargelenk-Sprengung mit einer resorbierbaren PDS-Kordel

Osteosynthetic complications in surgery of acromioclavicular separations are common. Also, one more intervention is necessary for removing the metallic implants. Use of self-resorbing materials resolves such disadvantages. One more indirect surgical method is presented. After reposition of dislocated acromioclavicular joint and suture of the disrupted ligaments clavicula is fixed to the coracoid processus by a cord of polydioxanone (=PDS). Early postoperative mobilisation without risks is possible in co-operative patients. Self-resorbing implantates don't modify the well known indications of conservative and operative treatment.     

Anatomy of the pectoralis minor tendon and its use in acromioclavicular joint reconstruction

Many procedures described for operative management of acromioclavicular joint separations entail transfer of the coracoacromial ligament. We sought to describe the anatomy and morphology of the pectoralis minor tendon better, to assess its anatomic potential as a substitute for sacrificing the coracoacromial ligament, and to compare the ultimate tensile strength of the pectoralis minor with that of the coracoacromial ligament and detached coracoclavicular ligament. The morphology of the pectoralis minor tendon was carefully delineated and compared with that of the coracoacromial ligament, and 10 paired fresh-frozen cadaveric shoulders were tested to failure by applying a single uniaxial tensile load. Anatomic study of the pectoralis minor tendon confirmed its adequacy as a source of local autograft tissue in acromioclavicular joint reconstruction. We hypothesize that, in cases of acromioclavicular joint separation necessitating operative intervention, the use of the pectoralis minor tendon as a potential source of autograft tissue is anatomically feasible and it is slightly stronger than the coracoacromial ligament.