Coracoclavicular ligament reconstruction using the lateral half of the conjoined tendon

To preserve the coracoacromial (CA) ligament, we have used the lateral half of the conjoined tendon as an autograft source to replace the coracoclavicular (CC) ligament. The purpose of this study is to compare the ultimate tensile strength of the lateral 12 mm of the conjoined tendon with that of the CA ligament and the CC ligament. Eight paired cadaveric male shoulders were tested to tensile failure with a custom pneumatic testing apparatus. Although the lateral 12 mm of the conjoined tendon was stronger than the CA ligament, this difference was not statistically significant (P =.37). However, the intact CC ligament (621 +/- 209 N) was approximately 250% stronger than either the lateral 12 mm of the conjoined tendon (265 +/- 79 N, P <.001) or the CA ligament (246 +/- 69 N, P <.001). We believe that the lateral half of the conjoined tendon is a viable alternative autograft source for reconstruction of the CC ligament in cases of symptomatic acromioclavicular joint dislocation. Though not as strong as the native CC ligaments, the conjoined tendon is slightly stronger than the commonly used CA ligament.     

应用异体肌腱重建喙锁韧带治疗肩锁关节完全脱位

目的：探索应用异体肌腱重建喙锁韧带治疗肩锁关节完全脱位一种新的手术方法。方法：从1997年10月2001年12月，共21例肩锁关节完全脱位患者，接受了经过深低温处理的同种异体屈指肌腱，采用在喙锁韧带 位置，穿过软组织隧道，行编织缝合，进行立体“8”字重建的治疗方法，恢复喙锁韧带在垂直方向对肩锁关节的稳定。在21例接受此治疗方法患者中，有19例得到了1年以上的随访。随访时间1240个月，平均16．8个月。结果：采用Lazzcano和Karlsson综合评分标准，优15例，良4例。X线片显示重建喙锁韧带部分骨化者2例。结论：异体肌腱重建喙锁韧带治疗肩锁关节完全脱位可以避免自体取材造成的副损伤及其引起的并发症，供材可提前制作，缩短了手术时间，减少了自体创伤。在组织工程移植尚未完全获得成功的今天，是一种可行的手术方法。     

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.     

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.     

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.     

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.     

Aktuelle operative Therapiestrategien bei chronischer Akromioklavikularsgelenkinstabilität

Chronic instability of the acromioclavicular joint (AC joint) results if the initial acromioclavicular joint luxation has been missed or if the rehabilitative or surgical treatment was not successful. Late repairs after a traumatic luxation are difficult to deal with because the biological healing response for reconstitution of the ligaments seems to be compromised. A meticulous diagnostic examination should be performed paying special attention to the character and direction of instability (static versus dynamic and vertical versus horizontal). For this purpose a specified classification system should be used (Hedtmann and Heers). A new surgical technique for stabilization of chronic AC joint instability has been established and biomechanically evaluated. The technique includes an augmented modified coracoacromial ligament (only the medial half of the ligament) transfer supplemented by coracoclavicular polyester augmentation. In an in vitro model the technique was shown to restore anterior and superior translation of the intact AC joint. An increase of translation compared to the level of the intact joint was statistically significant only for the posterior direction (127%, 3.8 mm intact versus 4.6 mm following reconstruction; p<0.05). Therefore, for further improvement of the technique some form of acromioclavicular ligament reconstruction (posterosuperior) could be profitable. In conclusion the presented surgical technique (augmented CA ligament transfer) reveals promising biomechanical results in an in vitro model and may serve as an alternative to current coracoclavicular ligament reconstruction techniques using autologous tendon grafts.     

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.     

Morphological study of mechanoreceptors on the coracoacromial ligament

We performed gold chloride staining of coracoacromial ligaments removed at operation, observed the peripheral nerve endings in the ligament, and studied their distribution and changes with aging in order to clarify the proprioception of the shoulder joint. The coracoacromial ligament was found to contain four types of typical nerve endings: Pacinian corpuscles, Ruffini receptors, Golgi tendon organ-like receptors, and free nerve endings. In addition, non-typical Pacinian corpuscles and Ruffini receptors with non-typical morphology were present. There were also unclassifiable nerve endings with a morphology which did not fit any of the above categories. These typical, non-typical, and unclassifiable nerve endings were all widely distributed on the surface of the subacromial side at the insertion into the acromion and around the coracoid process in the ligament. Free nerve endings were found sporadically on the surface of the subacromial bursal side in the ligament. The resected coracoacromial ligaments (23 specimens) were divided into two groups based on the disorder that required surgery: a fracture group without subacromial impingement (5 specimens) and a group with subacromial impingement (18 specimens). Age-related changes in the number of nerve endings were compared in each group. The total number of nerve endings decreased with age in both groups. The number of Pacinian corpuscles, Ruffini receptors, Golgi tendon organ-like receptors, and free nerve endings of typical morphology tended to decrease with age. The data from the fracture and subacromial impingement groups were not analyzed statistically because of the difference in the number of specimens in each group. However, the total number of nerve endings was lower in the subacromial impingement group than in the fracture group at all ages. The typical nerve endings of the coracoacromial ligament in both groups tended to decrease in the elderly, suggesting that the proprioception of the shoulder joint may become impaired with aging. Received for publication on June 16, 1997; accepted on Oct. 14, 1997     

The fate of the coracoacromial ligament in arthroscopic acromioplasty: an anatomical study

This study defines the normal anatomical relationships among the coracoacromial ligament, the deltoid, and the acromion in cadavers. The effect of arthroscopic acromioplasty on the acromial attachments of the coracoacromial ligament and the anterior fibers of the deltoid was also studied. After arthroscopic acromioplasty, the fibers of coracoacromial ligament and overlying deltoid inserting into the anterior part of the acromion remained attached to the acromion by a bridge of tissue composed of periosteum and collagen fibers of the coracoacromial ligament and deltoid tendon. We have called this the coracoacromial-deltoid-periosteal complex; it has not previously been described. This study demonstrates that arthroscopic acromioplasty preserves the acromial attachment of the coracoacromial ligament and the anterior fibers of the deltoid.     

Variations in method in the use of the coracoacromial ligament for the surgical treatment of acromioclavicular dislocations

Many authors have used the coracoacromial ligament to treat acromioclavicular dislocations. The variation in method proposed in this study includes: a) detachment of the coracoacromial ligament from the acromial aspect, b) its section into two bands, medial and lateral, of which one inserted by means of a transosseous hole at the clavicle and the second one anchored bridge-like on the clavicle suturing it to the soft tissues; c) temporary fixation of the acromioclavicular joint by means of a Kirschner wire or Ghisellini screw pin that is threaded at one end. The study conducted may be considered preliminary, as the series is constituted by 16 patients affected with grade IV acromioclavicular displacement according to Rockwood, acute in 13 cases and inveterate in 3. The results which were excellent and good in terms of pain, recovery of range of movement, and the subjective opinion of the patients, reveals a subdislocation measuring from 3 to 5 mm in 2 patients in our series. Currently, the hypothesis may be advanced that the variation in the method described may have the advantage of guaranteeing physiological anchoring of the ligament to the clavicle and thus providing a greater guarantee should trauma occur in the future.     

改良Weaver法治疗陈旧性重度肩锁关节脱位

目的 观察改良Weaver法治疗陈旧性重度肩锁关节脱位的临床疗效。方法 用1枚克氏针由肩峰通过肩锁关节穿入锁骨外端固定肩锁关节，喙肩韧带的肩峰端切断，旋转移位重建喙锁韧带。结果 23例术后随访1－5年，按优，良，差标准评定疗效，优19例（82．6％），良3例（13．0％），差1例（4．3％），优良率95．6％，结论 该方法操作简单，创伤小，远期疗效好，可满意恢复肩关节功能。     

In-vitro reconstruction of massive rotator cuff ruptures with triceps tendon or coracoacromial ligament

The possibility of reconstructing a massive rotator cuff rupture with a free graft of the triceps tendon or the coracoacromial ligament was tested experimentally in an anatomical and biophysical cadaver investigation. After dissection of the rotator cuff, a section of the supraspinatus tendon was removed to simulate a defect in the cuff. In dissection of the grafts, a bony squama was incorporated by osteotomy. The rotator cuff was reconstructed by suturing the free grafts into the defect. In addition, the bony squama was refixed in a prepared bone groove in the greater tuberosity of the humerus. The tensile strength and the elasticity of the grafts were compared with that of the supraspinatus tendon in rupture tests. The mean value of the maximum load determined (FRm) was greatest for the triceps tendon (706.451 N), while very much lower values were found for the coracoacromial ligament (395.836 N) and the supraspinatus tendon (496.792 N). The mean value of the maximum elasticity (LAm) was lowest for the coracoacromial ligament (4.701%); the supraspinatus tendon (7.047%) and the triceps tendon (8.250%) showed very much greater elasticity. Received: 6 November 1999     

应用不同手术方法治疗陈旧性肩锁关节脱位的疗效分析

目的比较分析应用不同手术方法治疗陈旧性肩锁关节脱位的疗效。方法对 43例陈旧性肩锁关节脱位患者分别应用单纯切开复位克氏针内固定 (9例 );切开复位内固定并肩锁关节韧带重建 (14例 );切开复位内固定并喙突上移 (20例 )三种手术方法进行治疗,术后平均随访 4.8年,对其自觉症状、上肢肌力、肩关节功能和肩锁关节间隙等改善程度进行比较。结果三种术式的优良率分别为 33％ (3/9)、 50％ (7/14)和 74％ (15/20)。单纯切开复位克氏针内固定法的疗效与切开复位内固定并肩锁韧带重建法相比,差异无显著性意义 (P >0.05),两者与切开复位内固定并喙突上移法比较,差异有显著性意义 (均 P< 0.05)。结论治疗陈旧性肩锁关节脱位的手术方法应达到 :(1)清除关节内瘢痕组织及软骨碎片; (2)重建关节纵向与水平稳定性; (3)施以有效内固定直至韧带修复,牢固愈合。     

Anterior acromioplasty for the chronic impingement syndrome in the shoulder. 1972

Impingement on the tendinous portion of the rotator cuff by the coracoacromial ligament and the anterior third of the acromion is responsible for a characteristic syndrome of disability of the shoulder. A characteristic proliferative spur and ridge has been noted on the anterior lip and undersurface of the anterior process of the acromion and this area may also show erosion and eburnation. The treatment of the impingement is to remove the anterior edge and undersurface of the anterior part of the acromion with the attached coracoacromial ligament. The impingement may also involve the tendon of the long head of the biceps and if it does, it is best to decompress the tendon and remove any osteophytes which may be in its groove, but to avoid transplanting the biceps tendon if possible. Hypertrophic lipping at the acromio-clavicular joint may impinge on the supraspinatus tendon when the arm is in abduction and, if the lip is prominent, this joint should be resected. These are the principles of anterior acromioplasty.     

可吸收材料和金属内固定治疗肩锁关节脱位疗效的比较

目的比较生物可吸收材料(Biopoly人工韧带)与金属内固定治疗肩锁关节完全脱位的疗效。方法采用两种方法治疗28例肩锁关节完全脱位。可吸收韧带组12例,采用人工韧带重建喙锁韧带和“8”字张力带重建肩锁韧带治疗;金属内固定组16例,采用克氏针结合钢丝张力带或螺钉结合钢丝张力带治疗。其中,男17例,女11例。均为新鲜脱位,脱位距就诊时间为0～8d,平均1.5d。结果28例均获随访,随访时间8～70个月,平均39.5个月。根据术后X线片和关节功能恢复情况评定疗效,局部功能评定参照Lazcano标准。可吸收韧带组:优10例,良2例;金属内固定组:优13例,良2例,差1例。两种治疗方法临床效果无统计学差异。结论生物可吸收人工韧带像金属内固定一样是治疗肩锁关节脱位较理想的方法之一,并具有无须二次手术取出内固定物的优点。     

自体双股掌长肌腱联合人工韧带重建喙锁韧带治疗肩锁关节脱位

目的:探讨应用自体双股掌长肌腱联合人工韧带重建喙锁韧带治疗肩锁关节脱位的手术方法及临床疗效。方法:2006年4月至2009年6月采用自体双股掌长肌腱联合人工韧带重建喙锁韧带治疗肩锁关节脱位31例,男18例,女13例;年龄18～60岁,平均35岁;急性损伤26例,慢性损伤5例。术前患者主要表现为不同程度肩部疼痛、活动受限、肩锁不稳,X线提示肩锁关节脱位。结果:术后切口愈合好,无一例血管及臂丛神经损伤。全部病例获得随访,平均时间23个月,JOA评分术前(38.8±1.5)分,术后1个月(73.2±1.1)分,末次随访(93.5±0.8)分。本组优28例,良2例,一般1例。结论:应用自体双股掌长肌腱联合人工韧带重建喙锁韧带同时行锁骨远端部分切除是治疗肩锁关节脱位的有效方法。     

Coracoacromial ligament release for shoulder impingement syndrome using the Universal Subcutaneous Endoscope system.

We developed a new operative procedure of coracoacromial ligament release for shoulder impingement syndrome. The operative procedure was confirmed by cadaveric studies and applied to clinical cases in 40 shoulders of 37 patients who suffered from shoulder impingement without bony abnormalities. The subacromial space was observed under local anesthesia using the Universal Subcutaneous Endoscope (USE) system on an outpatient basis. A popping phenomenon was observed between the coracoacromial ligament and the greater tuberosity of the humerus, which was covered by the rotator cuff, and the coracoacromial ligament was resected with a rongeur under endoscopic visualization in all shoulders. Resection of the coracoacromial ligament relieved the impingement and clinical signs, as in open or arthroscopic resection of the coracoacromial ligament. Resection of the coracoacromial ligament using the USE system is a safe and less-stressful surgical invasion than open or standard arthroscopic resection of the coracoacromial ligament.