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.     

Acromioclavicular Joint Reconstruction Using Peroneus Brevis Tendon Allograft

We describe the use of a double-strand peroneus brevis allograft to reconstruct the coracoclavicular and acromioclavicular (AC) joint ligaments. Through sharp dissection, the distal clavicle, the AC joint, and the torn superior AC and coracoacromial ligaments are identified. The coracoid process and injured coracoclavicular ligaments are identified with blunt dissection. A 1-cm segment of the lateral clavicle is resected. Vertical and connecting horizontal tunnels are created (4.5 mm) in the lateral clavicle and in the medial acromion process. The 5.5- to 6.0-mm-diameter allograft is looped around the coracoid process, and both strands are passed through the vertical clavicle tunnel with a nitinol wire loop. One strand passes through the vertical clavicle tunnel, and the other strand passes through the horizontal tunnel, exiting through the lateral end. The allograft strand passed through the vertical clavicle tunnel is then passed inferiorly through the superior vertical acromion tunnel, and the strand passed completely through the horizontal clavicle tunnel is passed laterally through the medial horizontal acromion tunnel. After both strands exit inferiorly through the vertical acromion tunnel, they are tensioned and sutured with AC joint reduction. Soft tissue closure uses No. 0 and No. 2-0 absorbable sutures with No. 3-0 nylon sutures at the skin.     

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.     

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。     

Treatment of distal clavicle fractures using an arthroscopic technique

Whenever indicated, distal clavicle fractures can be treated with a double loop of a nonabsorbable, #5 suture around the clavicle and under the coracoid. We developed an all arthroscopic technique to perform this procedure. From January to September 2004, 7 patients were treated. The mean age was 46 years. The coracoid is identified through the rotator interval. Using a special needle, a double #5 suture is passed around the coracoid. A hole is created at the clavicle and, through another guide wire, is sent to the anterior portal. The double #5 suture is transported to the clavicle. After the reduction of the fracture the sutures are tightened. All 7 cases have healed. The surgical treatment of these fractures is well established, and with the aid of arthroscopy, the morbidity can be decreased. The technique has been shown to be safe with no complications.     

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。     

关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位

目的探讨关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位的临床疗效。 方法回顾性分析上海交通大学医学院附属新华医院骨科采用关节镜辅助下三束重建治疗21例急性Rockwood Ⅲ型肩锁关节脱位患者的资料,均为闭合性损伤。术后3、6、12个月对所有患者进行术后临床效果和影像学评价。根据术后影像学资料评估复位再丢失情况,采用Constant评分和上肢功能（disabilities of arm,shoulder and hand,DASH）评分评估患者肩关节功能。探讨术中关节镜辅助治疗的意义和价值。 结果术中关节镜探查发现4例合并软组织损伤,并进行一期镜下修复。所有患者术后均未发生喙突骨折和襻断裂。影像学评估提示术后6~12个月有6例患者（28.6%）出现轻度复位丢失,但与Constant评分和DASH评分无显著相关性,没有患者要求取出内固定。 结论关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位是一种创伤小、安全、临床效果确切的手术方法。急性肩锁关节脱位通常由高能量损伤造成,在手术中关节镜探查肩关节能发现合并的软组织损伤,并进行一期修复,有利于肩关节功能的恢复,避免二次手术。     

锁骨钩钢板内固定术后肩部疼痛和外展受限的分析

目的探讨采用锁骨钩钢板内固定治疗锁骨远端骨折和肩锁关节脱位术后并发肩部疼痛和肩关节外展受限的原因。方法将60例锁骨远端骨折和肩锁关节脱位患者随机分为A、B两组。锁骨钩钢板外侧钩的安置采用两种不同方式：A组（30例）患者术中仅显露锁骨骨折断端及肩锁关节,不显露肩峰,锁骨钩钢板外侧钩于肩锁关节后方盲插入肩峰下进行固定;B组（30例）患者同时显露肩峰,将锁骨钩钢板外侧钩紧贴肩峰于骨膜下插入进行固定,以减少钢板钩部与肩峰之间软组织嵌入。对两组术后出现患侧肩关节疼痛不适及外展受限发生率进行组间对比分析。结果 55例患者获得12-24个月随访,5例失访。肩关节疼痛及外展轻度受限B组28例中出现3例,发生率为10.7%;A组27例中出现9例,发生率为33.3%,两组比较差异有统计学意义（P〈0.05）。结论术中充分显露肩峰,紧贴肩峰插入锁骨钩钢板外侧钩,使外侧钩部与肩峰紧密贴合,可减少其间软组织嵌入和肩峰与钢板钩部撞击,从而减少术后肩关节疼痛及外展受限等并发症的发生率。     

Editorial Commentary: Acute Repair of the Acromioclavicular Joint Capsule and Ligaments and Deltotrapezial Fascia Could Allow Biological Healing of High-Grade Acromioclavicular Separation—Coracoclavicular Ligament Graft Augmentation Could Be Indicated if Time to Surgery Is Greater Than 3 Weeks

Surgical management of chronic acromioclavicular joint (ACJ) dislocations is a matter of controversy. In the acute setting of high-grade acromioclavicular separation, if a surgical repair of the ACJ capsule and ligaments and deltotrapezial fascia could allow biological healing of the ligaments themselves, this could be enough to restore the functional biomechanics of the joint; unfortunately, this is not true for chronic cases. In the latter situation, a surgical technique using biological augmentation such as autograft or allograft should be preferred. Time is very important for this injury, and a chronic lesion should be considered when treatment is being performed 3 weeks after trauma. The graft should be passed around the base of the coracoid or through a tunnel at the base of the coracoid itself and then at the level of the clavicle as anatomically possible to reproduce the function of the native ligaments. However, some studies have shown that passing the graft at the base of the coracoid and wrapping it around the clavicle could also achieve satisfactory outcomes. An arthroscopic technique, when used in combination, could be great to treat the associated lesions, which have a reported percentage between 30% and 49%. Finally, to restore the biomechanics of the ACJ, however, reconstruction of the acromioclavicular superior and posterior capsules together with the deltotrapezial fascia seems to be very important.     

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。     

肩锁关节脱位和锁骨远端骨折两种固定方法的比较

目的比较采用插入式锁骨钩钢板与克氏针加张力带钢丝内固定治疗肩锁关节脱位和锁骨远端骨折的临床疗效。方法回顾分析我院1997～2005年采用克氏针加张力带钢丝固定治疗的91例肩锁关节脱位和锁骨远端骨折及2002-2007年采用插入式锁骨钩钢板固定治疗的57例肩锁关节脱位和锁骨远端骨折。复位骨折或脱位后，前者用1～2枚直径为2．0或2．5mm克氏针由外向内经肩峰穿入锁骨外1／3附近上方出针，加用张力带钢丝加强固定；后者先将锁骨钩钢板的钩部插入肩峰下，然后将钢板体部用螺钉固定于锁骨上。结果前者91例患者中80例获得12～18个月随访，74例患者正常愈合，6例患者出现克氏针松动退出，导致固定失败二次手术。后者57例患者中51例获得12～20个月随访，51例患者全部正常愈合，无一例固定失败。结论采用插入式锁骨钩钢板固定治疗肩锁关节脱位和锁骨远端骨折操作简单、固定可靠、成功率高，符合生物力学要求，术后功能康复快，明显优于克氏针加张力带钢丝固定。     

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。     

带袢钢板重建喙锁韧带与锁骨钩钢板治疗 锁骨远端骨折的病例对照研究

目的：探讨带袢钢板加爱惜帮缝线双束重建喙锁韧带和锁骨钩钢板治疗NeerⅡ型锁骨远端骨折的疗效差异。方法：2008年11月至2009年12月,采用带袢钢板加爱惜帮缝线双束重建喙锁韧带（A组8例）和锁骨钩钢板（B组10例）治疗18例锁骨远端骨折患者,其中男10例,女8例,年龄28～65岁,平均38岁。所有损伤均为新鲜损伤,X线表现为NeerⅡ型锁骨远端骨折,损伤至手术时间为2～5d,平均2.8d。所有患者受伤前肩关节活动均正常。术后第1、2、3个月对患肩功能用Constant Murley评分系统进行评分。结果：两组患者切口均Ⅰ期愈合,无感染发生,无臂丛神经损伤。X线提示,所有骨折在术后3个月时有连续骨小梁通过,证实骨折愈合。所有患者均获得随访,时间3～8个月,平均5.7个月。术后第1、2、3个月,A组Constant Murley评分分值分别为：（91.4±6.7）、（97.5±2.6）、（98.3±2.0）分;B组分别为：（70.1±5.1）、（89.0±7.6）、（94.2±4.6）分。在术后1、2、3个月,A组的肩关节评分均高于B组,差异具有统计学意义（P〈0.05）。结论：带袢钢板加爱惜帮缝线双束重建喙锁韧带治疗NeerⅡ型锁骨远端骨折,由于不影响肩锁关节,患者可以获得更好的肩关节功能,虽然这一固定方式是非坚强固定,但是所有骨折均愈合。这一技术的应用有赖于完整和坚强的喙突,在小喙突和骨质疏松的患者中可能不适用。     

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.     

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.     

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.     

关节镜下Twin Tail TightRope带袢钛板Y型固定治疗急性RockwoodⅢb型以上肩锁关节脱位的早期疗效

目的评价Twin Tail TightRope带袢钛板Y型固定术治疗急性肩锁关节脱位的早期临床疗效。 方法回顾性分析2015年6月至2017年6月昆明市第一人民医院采用Twin Tail TightRope带袢钛板内固定系统在关节镜下行Y型固定治疗急性肩锁关节脱位患者共16例。采用视觉模拟评分法（visual analogue scale，VAS）及Constant-Murley评分评估手术效果。 结果所有患者获得随访，随访时间3~12个月，平均（6.48±1.51）个月。术后无血管、神经损伤及切口感染，末次随访时均未发生复位丢失、锁骨应力性骨折、喙突切割等并发症。末次随访时VAS评分（0.36±0.04）分较术前（7.46±1.24）分降低，Constant-Murley评分（90.07±3.13）分较术前（46.13±3.25）分提高。 结论采用Twin Tail TightRope带袢钛板Y型固定术治疗急性肩锁关节脱位可有效解决术后水平、前后方向不稳定问题，此技术具有较低的锁骨、喙突骨折发生率，关节镜下操作可以减少手术损伤、提高精准度。     

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。     

联合带线锚钉功能重建锁骨远端Neer Ⅱb型骨折中喙锁韧带的意义

目的探索用锁骨远端解剖锁定板治疗锁骨远端Neer Ⅱb型骨折,同时联合使用带线锚钉对喙锁韧带进行功能重建的意义及其必要性。 方法回顾分析手术治疗的锁骨远端Neer Ⅱb型骨折41例患者,用锁骨远端解剖锁定板治疗21例,用锁骨远端锁定板并联合带线锚钉重建喙锁韧带20例。分别测量两组患者X线片术前、术后以及随访终末的喙突及锁骨间距离,用视觉模拟评分法进行术后疼痛评分,用美国加州洛杉矶大学UCLA功能评分法进行肩关节功能评测。将数据进行对比,分析两种术式的差异。 结果41例患者随访时间为6~26个月,平均14.5个月。X线片显示锁骨骨折均获得骨折愈合,未见明显骨折移位及内固定物断裂。两组手术方式患者术后疼痛评分及肩关节功能评分无明显差异,两者术后及末次随访的喙锁间隙差异显著。 结论联合使用带线锚钉功能重建喙锁韧带治疗锁骨远端Neer Ⅱ型骨折可以带来更好的肩锁关节垂直方向的稳定性,允许早期的功能锻炼。