Current concepts in management of ACJ injuries

Acromioclavicular joint injury is common in young individuals who suffer direct trauma to the shoulder. Treatment of acromioclavicular dislocation is controversial with regards to the indication of operative management, timing of surgery, whether to perform open or arthroscopic surgery, method of stabilisation (rigid or non-rigid) and type of graft used for repair or reconstruction. Current evidence supports conservative management for Rockwood types I and II, while types IV, V and VI benefit from surgery. The optimal management of type III injuries in high demand patients remains contentious. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Few studies with a low level of evidence suggest arthroscopic techniques and anatomical ligament reconstruction have better outcomes when compared to older techniques of rigid coracoclavicular fixation. The aim of this article is to look at the current evidence and address these controversial issues.     

Percutaneous cannulated screw coracoclavicular fixation for acute acromioclavicular dislocations

In 1941, Bosworth introduced a new method of repairing acute complete acromioclavicular dislocations in which a noncannulated coracoclavicular lag-screw was inserted by a blind technique. The author reintroduces the percutaneous coracoclavicular fixation concept. A cannulated screw was specially designed, and the technique of percutaneous insertion under fluoroscopic image control was developed. Fifty-three acromioclavicular dislocations were treated by this method. There were 40 Type III, five Type IV, and three Type V dislocations with distal clavicle fractures in conjunction with complete coracoclavicular ligament tears. Technical failures, which occurred in 17 of 53 patients (32%) included: failed percutaneous insertion in two; early screw pullout in three; late screw pullout in four; subluxation after screw removal in six; and malreduction of Type IV dislocation in two. There was no screw breakage or evidence of migration. Serous drainage occurred in two patients.     

Subcoracoid dislocation of the acromioclavicular joint

Subcoracoid acromioclavicular dislocations are rarely seen injuries of the shoulder. We present a patient with multiple injuries and a subcoracoid acromioclavicular dislocation resulting from a falling injury. Physical examination revealed painful mechanical block at 90 degrees of abduction and swelling in the acromioclavicular region. Diagnosis was made with direct radiographs and computerized tomography. Treatment consisted of distal clavicular resection and coracoclavicular reconstruction with the transfer of the coracoacromial ligament over the clavicle. The patient had a pain-free shoulder after two years and was capable of performing daily activities despite the presence of coracoclavicular ossification.     

锁骨中段骨折合并同侧肩锁关节脱位：诊断要点分析研究

目的探讨锁骨中段骨折合并同侧肩锁关节脱位的诊断要点,为临床早期诊断该类损伤提供参考。 方法通过分析国内外文献报道的病例,并回顾性分析本科室随访病例,从年龄、性别、受伤原因、锁骨中段骨折及肩锁关节脱位分型等方面进行分析。 结果共检索到19篇锁骨中段骨折伴同侧肩锁关节脱位的英文病例报道、7篇中文文献病例报道,其中有清晰术前X线片的病例共22例。同时,回顾性分析了本院临床随访的2例该类病例,因此,最终有24例病例纳入分析研究。其中,男16例、女8例;最小年龄为19岁,最大年龄为65岁,平均年龄为37岁。大部分由高能量损伤所致（21/24, 87.5%）。锁骨骨折类型分型：19例（19/24,79.2%）属于A型骨折,5例（5/24,20.8%）属于B型骨折;肩锁关节脱位分型：IV型12例（50.0%）、III型6例（25.0%）,VI型4例（16.7%）,V型2例（8.3%）;9例（9/24,37.5%）患者有合并损伤。 结论对于高能量损伤导致的相对简单类型的锁骨中段骨折,需高度怀疑有无同侧肩锁关节脱位,诊断要点如下：（1）详细询问受伤原因,了解受伤机制;（2）对所有锁骨中段骨折病例,需观察肩锁关节处有无肿胀、皮下青紫,并对肩锁关节及喙突处进行压痛体格检查,如有压痛,则高度怀疑肩锁关节损伤;（3）需仔细观察术前X线肩锁间隙及喙锁间隙变化,如锁骨中段骨折为相对简单类型,且为高能量损伤者,需高度怀疑,建议加拍对照位片及患侧肩关节CT检查;（4）术中锁骨中段骨折固定后,常规透视同侧肩锁关节。     

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.     

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.     

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.     

Evaluation and management of acromioclavicular joint injuries

The acromioclavicular joint is stabilized by the coracoclavicular and acromioclavicular ligaments and by the trapezius and deltoid muscles. Joint dislocation commonly results from a direct blow to the acromion. Injury types I through III are generally treated nonoperatively, whereas types IV through VI are treated operatively. Nonoperative protocols should always begin with ice and immobilization. Operative techniques include acromioclavicular ligament repair, dynamic transfer of the conjoined tendon, coracoclavicular ligament reconstruction, and coracoacromial ligament transfer. The goal with any injury type should always be full return to the patient's preinjury condition.     

Acute acromioclavicular dislocations

Acromioclavicular dislocations represent over 10% of acute traumatic injuries to the shoulder girdle. The mechanism is usually a direct impact on the shoulder with the arm in adduction, producing rupture of the acromioclavicular (AC) ligaments, then of the coracoclavicular (CC) ligament, with displacement of the lateral end of the clavicle. Rockwood described 6 grades of injury. Physical examination usually provides the diagnosis, which is confirmed by radiological examination. X-rays centered on the AC joint, if necessary with forceful adduction of both shoulders or under traction, are useful to evaluate the severity of the lesion. Grade I and II lesions are usually treated conservatively by simply immobilizing the arm for 3 to 4 weeks. Surgical treatment is usually advocated for grade IV, V and VI lesions: AC or CC fixation, sometimes associated with ligament repair, depending on the surgeons. AC pinning or C-C screw fixation are the techniques most often used. Management of grade III lesions remains controversial. Some authors advocate immediate surgical treatment in young, active patients, in heavy laborers and even in slender individuals. The choice of the operative technique is controversial, as no single technique has clearly proved to be superior to others. Other authors advocate conservative treatment, which gives functional results which patients consider quite acceptable, with faster recovery; patients should be informed that results are essentially similar, whatever the treatment. The possibility of performing secondary operations with good results in cases with failure of conservative management is a further argument in favor of applying conservative therapy first in acute injuries.     

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。     

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。     

保守治疗与锁骨钩钢板内固定手术治疗Rockwood Ⅲ型肩锁关节脱位的中长期疗效对比研究

目的通过对比评估分析保守治疗与锁骨钩钢板内固定手术治疗Rockwood Ⅲ型肩锁关节脱位的中长期临床疗效,为临床上该类型肩锁关节脱位的治疗方式的选择提供依据。 方法回顾性分析自2015年9月至2016年9月在中山市中医院关节科诊治为Roockwood Ⅲ型肩锁关节脱位的患者,入选72例,成功随访47例,采用锁骨钩钢板内固定治疗（钩钢板组）23例、采用保守治疗方法（保守治疗组）24例。随访观察比较两组术后（损伤后）1年、3年、5年视觉模拟评分法（visual analogu scale,VAS）、肩关节功能评分以及并发症发生率。 结果术后1年随访锁骨钩钢板组VAS评分稍优于保守治疗组,但两组差异无统计学意义（P>0.05）;而术后3年以及5年锁骨钩钢板组VAS评分均明显优于保守治疗组,且差异具有统计学意义（P<0.05）。术后1年、3年以及5年随访锁骨钩钢板组肩关节功能评分均明显优于保守治疗组,且差异具有统计学意义（P<0.05）;锁骨钩钢板组并发症发生率明显低于保守治疗组,且差异具有统计学意义（P<0.05）。 结论采用锁骨钩钢板内固定手术治疗Rockwood Ⅲ型肩锁关节脱位,治疗效果较好,是治疗肩锁关节Rockwood Ⅲ型肩锁关节脱位较好的方法。     

Arthroscopic Treatment of Acute and Chronic Acromioclavicular Joint Dislocation

This article presents an all-arthroscopic technique for coracoclavicular ligament reconstruction by ligamentoplasty after acute or chronic acromioclavicular joint dislocation. A coracoacromial ligament transfer is done to reconstruct the torn coracoclavicular ligaments, similar to open surgery. The coracoacromial ligament is dissected from the undersurface of the acromion and is reinserted on the inferior clavicle by transosseous suture fixation. Additional wire or screw stabilization may be used. With this method, we achieve a very satisfactory reduction of the dislocated acromioclavicular joint.     

Distal fracture clavicle and acromioclavicular dislocation: a case report and review the literature

Acromioclavicular dislocations and clavicle fractures are extremely common injuries. However, complete acromioclavicular dislocation combined with an adjacent clavicle fracture is very rare. Its recognition depends on a thorough assessment of the patient, including high-quality radiographs of the clavicle and acromioclavicular joint. This report describes an unusual injury: an acromioclavicular dislocation type III with a distal clavicle fracture type I in the same arm. The patient was treated conservatively with an immobilization for 6?weeks. After 9?months of follow-up, the patient had a pain-free shoulder with full range of motion.     

Surgical reconstruction of the acromioclavicular joint: Can we identify the optimal approach?

Injuries to the acromioclavicular (AC) joint are common, tending to occur secondary to traumatic injuries. Rockwood grade IV, V and VI injuries involve complete dislocation of the joint and require surgical reconstruction, with inconclusive literature on whether grade III injuries should be surgically or conservatively managed. There are over one hundred reported surgical techniques which reconstruct the AC joint, with little indication of which methods achieve the best results. Techniques can generally be considered as: anatomical reduction; CC ligament reconstruction; and anatomical reconstruction. Techniques which implant hardware to reduce the AC joint, such as the hook plate, are commonly implemented, but have been shown to alter the mechanics of the joint significantly, resulting in poor short-term and long-term outcomes. Methods which reconstruct both the acromioclavicular and coracoclavicular ligaments are comparatively new, and early reports suggest that they achieve biomechanical properties similar to the native joint. More focus should be placed on such techniques in the future to determine whether they offer a more suitable approach to improve patient outcomes following AC joint reconstruction.     

A modified method of coracoid transposition for the treatment of complete dislocation of acromioclavicular joint

Objective:To eport a new method of coracoid transpostiton for the treatment of complete dislocation of acromioclavicular joint and to evaluate its efficacy.Methods:We modified Eewar‘s surgical method as follows:(1)Two small incisions,a transversal incision on the acromioclavicular joint and a longitudinal incision on the coracoid ,were made instead of a conventional large arc incision from the acromion to coracoid.(2)The foreign body in the acromioclavicular joint was cleared out.Thechondral surface at the lateral segment of clavicle was resected to form a pseudarthrosis and meanwhile the residual joint capsule and ligaments were repaired.(3)The coracoid was moved to the anteroinferior edge of the clavicle instead of the anterior margin and (4)the coracoid was moved to the lateral border of the clavicle instead of the superior border of the coracoclavicular ligament.Results:The follow-up duration in 30patients of the series was from6to 72months(mean41months).Functional assessment was carried out by the criteria delineated previously by Karkson,in which Grade Awas in 24 cases,Grade Bin4cases,and Cin2.Conclusions:This modified technique,having less postoperative complications and less injuries to tissues and according well with the requitement of biomechanics,can achieve a stable reduction of acromioclavicular joint with a good functional and cosmetic result and thereore is preferable to use clinically on a large scale.     

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。     

关节镜下喙锁和肩锁韧带重建治疗陈旧性Rockwood III型肩锁关节脱位

目的探讨关节镜下喙锁+肩锁韧带重建治疗陈旧性Rockwood III型肩锁关节脱位的疗效。 方法选取2016年1月至2020年12月北京大学人民医院收治的14例确诊为陈旧性肩锁关节脱位患者,其中男8例、女6例,平均年龄（37.2±10.1）岁,平均受伤时间（13.4±3.5）个月,累及优势侧肩关节7例,均行关节镜下喙锁+肩锁韧带重建手术。术后所有患者分别于不同时间点随访（术后1、3、6、12个月）,进行视觉模拟评分（visual analogue scale,VAS）和美国加州大学洛杉矶分校（University of California, Los Angeles,UCLA）评分。 结果14例确诊为陈旧性肩锁关节脱位患者（均为Rockwood III型）进入研究并完成手术,12例获得完全随访,平均随访（26.3±8.6）个月（12~36个月）。患者术前和术后1个月、3个月、6个月、12个月VAS评分分别为（5.667±0.414）分、（5.583±0.288）分、（4.583±0.229）分、（2.833±0.271）分、（0.538±0.193）分,与术前相比,所有患者在术后3个月、6个月和12个月随访时均显示疼痛减轻,术后6个月和12个月疼痛减轻的程度与术前相比（VAS评分变化）差异有统计学意义（P<0.001）。患者术前和术后1个月、3个月、6个月、12个月UCLA评分分别为（19.083±0.468）分、（18.583±0.434）分、（21.000±0.628）分、（25.750±0.579）分、（32.750±0.509）分,与术前相比,所有患者在术后3个月、6个月和12个月随访时UCLA评分与术前相比均有提高,术后6个月、12个月随访时UCLA评分改善的程度与术前相比,差异有统计学意义（P<0.001）。 结论关节镜下喙锁+肩锁韧带重建可以用较小的创伤达到帮助陈旧性肩锁关节脱位患者减轻疼痛和改善肩关节功能的目的。