Coracoclavicular Research Articles

Arthroscopic-assisted stabilization of distal clavicle fractures with coracoclavicular ligament injury: does it restore anatomy and function?

Abstract Background Fractures of the lateral-third clavicle are less common than the mid-shaft. However, these lateral thirds are associated with disruption of coracoclavicular (CC) ligaments requiring surgical management for optimal fracture healing and functional outcome. Many surgical techniques have been developed to manage these fractures; however, high failure rates and implant-related complications were reported. This study aims to assess the radiological and functional outcomes of arthroscopic-assisted stabilization of the distal end clavicle in terms of union rate, complications, and shoulder function. Patients and methods A prospective study of 32 patients with distal displaced clavicle fracture combined with CC ligament injury (Neer type IIB, V) who underwent surgery within the first 2 weeks of injury between January 2017 and February 2020. Clinical evaluation was employed postoperatively using the Constant–Murley score. The stability of the acromioclavicular joint in the horizontal and vertical planes was evaluated by the cross-arm test and manual dislocation. Radiological assessment was reviewed by an independent observer who was not a surgical team member at 1 and 2 months postoperatively. Results A series of 32 patients (24 men and eight women) were included. Their mean age was 36 years. Based on the radiological imaging, 20 patients had Neer type-IIB fractures, while 12 showed type-V fractures. Their average union time was 6.12 ± 1.26 weeks (ranged 5–9 weeks), with a mean Constant–Murley score that was 96.1 ± 3.76 (range, 89–100). An average of 6.62 ± 1.82 weeks was needed before returning to prior activities. There were no complications reported. Conclusions Arthroscopic-assisted fixation of the distal end clavicle provides excellent fixation results and restores the native anatomy by reconstructing the torn CC ligament without complications or the need for removal of the implant.

Accelerated rehabilitation in treating neer type V distal clavicle fractures using anatomical locking plates with coracoclavicular ligament augmentation

BackgroundThere is still no gold standard treatment for Neer type V distal clavicle fractures. This study was designed to evaluate the therapeutic effects of accelerated rehabilitation in treating Neer type V fractures using anatomical locking plate (ALP) fixation with additional coracoclavicular (CC) ligament augmentation. MethodsIn this retrospective study, patients who underwent ALP fixation with additional suture anchor fixation of acute Neer type V distal clavicle fracture from January 2016 to January 2021 were reviewed. Injury radiography and computed tomography (CT) were performed to determine the Neer classification. All patients performed standardized early rehabilitation exercises after surgery and were followed up for more than 12 months. The Constant–Murley score (CMS); the disabilities of the arm, shoulder, and hand (DASH) questionnaire; visual analog scale (VAS); and the percentage of modified CC distance (MCCD%) were evaluated at the last follow-up. ResultsThirty-two patients were included in this study. The mean follow-up time was 31.1 ± 10.4 months. All patients achieved bone union 6–8 weeks (7.2 ± 0.7 weeks) after surgery and were allowed to return to normal daily life. No surgery-related complications occurred in any case. The MCCD% value at the last follow-up (104.7% ± 8.5%) significantly decreased compared with preoperative MCCD% value (162.8% ± 7.2%) (p < 0.001), indicating that all patients achieved ideal fracture reduction. And all patients obtained satisfactory shoulder joint function with a mean CMS of 97.1 ± 2.6, a mean DASH score of 1.6 ± 1.3, and a mean VAS score of 0.4 ± 0.6. ConclusionThis study has demonstrated that ALP fixation with additional suture anchor fixation is a promising strategy for accelerated rehabilitation in treating patients with Neer type V fracture.

SURGICAL TREATMENT OF ACROMIOCLAVICULAR DISLOCATION: HOOK PLATE VERSUS SUTURE BUTTON.

We aimed to compare the functional and radiographical outcomes of reconstruction of acute unstable acromioclavicular joint (ACJ) dislocation using Hook Plate (HP) versus Suture Endobutton (SE) fixation techniques. Forty-six consecutive patients with grade III to V ACJ dislocation according to Rockwood classification who underwent either HP or SE fixation in the period between January 2017 and June 2020 were evaluated. The treatment modalities were divided into either HP or SE fixation. The radiological assessment included standard anterior-posterior (AP) views to evaluate coracoclavicular (CC) distances for vertical reduction. CC distances were grouped as preoperative (CC1), early postoperative (CC2), and late postoperative (CC3). The distance variance between CC2 and CC3 was referred as ΔCC (CC3 - CC2). A statistically significant difference was found in ΔCC between the two groups (p=0.008). ΔCC was significantly higher in the SE group compared to the HP group (p<0.05). The Constant and UCLA Scores of patients in the SE group were found to be significantly higher than in the HP group patients. Clinical outcomes were more satisfactory in patients with acute unstable ACJ dislocation who underwent SE compared to HP procedures, at the end of the first year. Evidence Level IV; Case Series.

Acromioclavicular Joint Problem in Athletes

Introduction: Acromioclavicular (AC) joint separations account for 12% of all shoulder injuries. People doing high-energy physical activities such as athletes are at risk for AC joint separation. The mechanism of injury could be direct or indirect. Direct mechanism involves a direct blow to the AC and coracoclavicular (CC) ligaments. Indirect mechanism happens when the injury force hits the AC joint indirectly, involving axial compression, as seen in a fall with an extended arm, where caput humeri is pressed against the acromion. The purpose of this paper is to elaborate on AC joint problems in athletes by reviewing literatures. Review: Patients with AC joint injury will exert complaints of pain and be unwilling to lift the affected arm, implying mobility function impairment. Signs such as skin abrasions and bruises can be found during inspection. A prominent distal clavicle is a pathognomonic sign of dislocation of the AC joint. A well-known classification for AC joint separations, Rockwood classification, divides the separations into six types. The classification helps determine different managements and prognoses for each of the AC joint separation types. Athletes should be treated in consideration of their position in the sports season. For athletes in season, pain should be treated as the priority. Absolute indications for surgical management are then identified to help determine the athlete’s return-to-play capability. For out-of-season athletes with AC injury, look for absolute or relative indications for operative management. If there is no indication, plan for rehabilitation. But if there are some indications, either absolute or relative, plan for surgery immediately. Complaints of pain and functional disabilities such as motion should be carefully assessed and managed. To determine suitable management, the injury should be classified properly. Type I and II injuries are treated with nonsurgical management. For type IV and VI injuries, surgical intervention is needed. AC joint separation Rockwood type III and V both had complete AC and CC ligament tear but repair is adequate for acute type III AC injury while reconstruction is needed for type V AC injury. Conclusion: AC joint separations should be treated as joints, not as bones where compressions are applied therefore limiting movements. Repair and reconstruction indications should be properly assessed on patients to ensure functions returned to their pre-injury state which is important for athletes’ return to sports.

Triple Disruption of the Superior Shoulder Suspensory Complex - Review and Surgical Technique.

The shoulder girdle is composed of two arches, and these two arches are held together by the superior shoulder suspensory complex (SSSC), a ligamentous complex. Goss's 1993 description of the SSSC as a ring includes the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion. Goss also noted in a 1996 study that a rupture of the SSSC in two places can result in an unstable lesion. This case report presents an unusual association of fractures involving the coracoid process, acromion, and distal clavicle, which has rarely been reported in the literature. Indeed, a triple lesion of the SSSC is very uncommon and the treatment is still debated. Therefore, we propose a surgical technique which we believe to have provide good results. A 54-year-old Caucasian male patient presented with Neer I distal third fracture of the clavicle, a displaced fracture of the acromion, and a fracture of the coracoid process following a left shoulder trauma after an epileptic crisis. The patient underwent surgery and has been followed for 1 year with good clinical and functional outcomes. This case report highlights the complexity of lesions of the SSSC and the importance of determining proper surgical technique based on the type of lesion. It demonstrates that surgery combined with active rehabilitation can lead to good functional outcomes for patients with this type of injury. This report will be of interest to clinicians involved in the treatment of this type of lesion and should add a valuable treatment option for the treatment of triple disruption of the SSSC.

Coracoclavicular and acromioclavicular ligament reconstruction with a cost-effective and reproducible method: A new surgical technique

Background: Treatment of Acute Acromioclavicular joint injuries is controversial with varieties of treatment modalities. Newer treatment methods are expensive requiring additional cost and advance devices assistance. This technique demonstrates a very cost-effective (less than USD 25) method of fixing Acromioclavicular joint injuries suitable for developing nations.Methods: From Year 2021 to 2023 we have performed 14 cases (aged 35-65 years) with good results with new surgical technique that utilizes 3- and 4-hole mini stainless-steel plates with no. 5 polyester suture, anatomic landmarks drilling based on study by Nai-Feng Zhu et al. (2015), and additional secure fixation at Acromioclavicular joint. Only 2mm drill holes were used to avoid suture creep. No arthroscopy assisted device, titanium endo-buttons, tension-band, special hardware were used. All patients were counselled for strict post-op rehabilitation protocol for 3 months before full range of motion activities were allowed.Result: This surgical technique provided secure fixation at coracoclavicular joints as well as acromioclavicular joints with 2mm drill portals with minimum suture creep.Conclusion: Our technique represents an anatomical, very cost-effective, and very reproducible way for treating acute AC joint separations especially focusing on developing countries.

Anatomic Acromioclavicular Joint Reconstruction Using Semitendinosus Graft with Internal Bracing in Chronic Acromioclavicular Joint Dislocation: Case Series

Introduction: Acromioclavicular joint dislocations represent a frequent condition, affecting a very specific and generally active population and accounting for around 9% of all shoulder injuries. Case Presentation: We present a series of patients who underwent AC Joint reconstruction using Semitendinosus graft with internal bracing. The beach chair position is used for acromioclavicular reconstruction surgery. In this technique, we restore the anatomy, reconstruct the coracoclavicular ligament, and reinforced the acromioclavicular ligament. And it is reliable for chronic acromioclavicular joint injury. At final follow up we found excellent results with average pain score of 1.6, and average ROM of 160° of forward flexion and abduction, 70° of external rotation, and internal rotation level at T11. Postoperative function also showed great improvements with average ASES of 85 points, an average Constant Score of 89 points. This technique also achieved acceptable radiographic results, with an average coracoclavicular distance increase of 1.4 mm Discussion &amp; Conclusion: The loss of AC joint congruence with the Weaver Dunn procedure suggested that possibly the problem wasn’t only biological. This technique seems to be especially advantageous as it allows for an anatomic, biological, and minimally invasive procedure while avoiding some of the inconveniences described in other reports. Although demanding, it can be reproducibly performed arthroscopically, and good clinical outcomes should be expected.

ANATOMICAL AND BIOMECHANICAL ROLE OF STATIC STABILIZERS OF THE ACROMIOCLAVICULAR JOINT.

The aim: To determine the anatomical and biomechanical significance of the static stabilizers of the acromioclavicular joint by conducting numerical modeling using the finite element method and experimental investigation. Materials and methods: To ensure the study, modeling of the deformation processes of the clavicle and scapula systems with various combinations of ligament damage was conducted. The COMPAS-3D software package was used to build the simulation model, which allowed obtaining models that are closest to reality. To verify the results of the numerical modeling, corresponding studies of the mechanical characteristics and determination of the stiffness of the investigated systems were carried out using the upgraded TIRAtest-2151 testing stand. Results: The stiffest system is the system in which all ligaments are intact, and the sequence of decreasing stiffness of the system is presented in the following order: damage to lig. trapezoideum; lig. conoideum; lig. claviculo-acoacromiale inferior; lig. claviculo-acoacromiale superior; the coracoclavicular ligament complex; the acromioclavicular ligament complex. Conclusions: Static stabilizers in general, and their components in particular, are characterized by significant anatomical and functional features. The natural stabilization of the acromioclavicular joint is provided by their synergistic interaction, which is the basis for the development and implementation of surgical interventions, the scope of which includes the restoration of both ligament complexes. The loss of stiffness in the «clavicle-scapula» system is significantly more pronounced when lig. acromioclaviculare superior and inferior are damaged (8.5 N/mm) than when lig. conoideum and lig. trapezoideum are damaged (11.6 N/mm).

Return to Play After Shoulder Surgery in Professional Baseball Players: A Systematic Review and Meta-analysis.

The current literature lacks an updated review examining return to play (RTP) and return to prior performance (RTPP) after shoulder surgery in professional baseball players. To summarize the RTP rate, RTPP rate, and baseball-specific performance metrics among professional baseball players who underwent shoulder surgery. Systematic review; Level of evidence, 4. A literature search was performed utilizing the PubMed, MEDLINE, and CINAHL databases and according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were English-language studies reporting on postoperative RTP and/or RTPP in professional baseball players who underwent shoulder surgery between 1976 and 2016. RTP rates, RTPP rates, and baseball-specific performance metrics were extracted from qualifying studies. A total of 2034 articles were identified after the initial search. Meta-analysis was performed where applicable, yielding weighted averages of RTP and RTPP rates and comparisons between pitchers and nonpitchers for each type of surgery. Baseball-specific performance metrics were reported as a narrative summary. Overall, 26 studies featuring 1228 professional baseball players were included. Patient-level outcome data were available for 529 players. Surgical interventions included rotator cuff debridement (n = 197), rotator cuff repair (RCR; n = 43), superior labrum from anterior to posterior repair (n = 124), labral repair (n = 103), latissimus dorsi/teres major (LD/TM) repair (n = 21), biceps tenodesis (n = 17), coracoclavicular ligament reconstruction (n = 15), anterior capsular repair (n = 5), and scapulothoracic bursectomy (n = 4). Rotator cuff debridement was the most common surgical procedure, while scapulothoracic bursectomy was the least common (37.2% and 0.8% of interventions, respectively). Meta-analysis revealed that the RTP rate was highest for LD/TM repair (84.5%) and lowest for RCR (53.5%), while the RTPP rate was highest for LD/TM repair (100.0%) and lowest for RCR (27.9%). RTP and RTPP rates were generally higher for position players than for pitchers. Nonvolume performance metrics were unaffected by shoulder surgery, while volume statistics decreased or remained similar. RTP and RTPP rates among professional baseball players were modest after most types of shoulder surgery. Among surgical procedures commonly performed on professional baseball players, RTP and RTPP rates were highest for LD/TM repair and lowest for RCR.

Functional and radiographic outcomes after allograft anatomic coracoclavicular ligament reconstruction

Functional and radiographic outcomes after allograft anatomic coracoclavicular ligament reconstruction

Functional and Radiological Outcome after Anatomic Coracoclavicular Ligament Reconstruction for Type III to Type V Acromioclavicular Joint Dislocation Using Semitendinous Autograft

INTRODUCTION: Acromioclavicular joint dislocation is a commonly encountered shoulder injury. Various surgical methods are available for the treatment of complete ACJ dislocation (type III to VI), however, optimal surgical treatment is still controversial. The purpose of this study was to evaluate the radiological and functional outcome of anatomic coracoclavicular reconstruction (ACCR) using semitendinosus autograft with suture augmentation for type III to V ACJ dislocation. MATERIALS AND METHODS: It was a single centered, cross sectional, observational study conducted at Department of Orthopedics and Traumatology, Dhulikhel Hospital. Twenty-three consecutive patients who underwent ACCR with semitendinosus autograft from Jan 2017 to Dec 2019 were included in the study. Patients below 18 years of age and patients with previous ipsilateral shoulder injury were excluded. The radiological outcome was assessed using coracoclavicular (CC) distance and functional outcome using DASH score and Constant score. Paired t-test and Pearson correlation were used for inferential analysis. RESULTS: Mean age of the patient was 33.83 ± 7.08 years. Mean duration of follow up was 28.17 ± 6.19 months. Mean CC distance at final follow up was 9.93 ± 1.12 mm. Mean DASH score was 5.60 ± 5.35 and mean Constant score was 88.04 ± 12.13. There were 12 (52.17%) excellent outcomes, 6 (26.08%) good outcomes, 2 (8.69%) fair outcomes and 3 (13.04%) poor outcomes based on Constant scores. CONCLUSIONS: ACCR with suture augmentation is an effective method for management of type III to V acromioclavicular joint dislocation.

The stress and strain pattern in the ligaments of the acromioclavicular joint using a quasi-static model

BackgroundThe precise role of the acromioclavicular and coracoclavicular ligaments during shoulder motion is unclear. We evaluate changes in the stress-strain distribution of the acromioclavicular joint's ligaments during different shoulder passive motion positions. MethodsA 3D acromioclavicular joint model was reconstructed. A constitutive hyperelastic model was used for the ligaments. The kinematics of the shoulder girdle was taken to simulate shoulder abduction (Motion 1) and horizontal adduction (Motion 2). A computer-generated quasi-static and non-linear finite element model was used to predict the 3D stress-strain distribution pattern of the acromioclavicular ligament and the coracoclavicular ligament complex. FindingsIn motion 1, from 20 to 90° the peak von Mises stress was found in the conoid (4.14 MPa) and the anteroinferior bundle (2.46 MPa), while from 90 to 120° it was found in the conoid and the trapezoid. However, there were no significant differences between the mean stress values between anteroinferior bundle and trapezoid throughout the motion (p = 0.98). In Motion 2, from 20 to 80° the maximum equivalent elastic strain was found in the anteroinferior bundle (0.68 mm/mm) and the conoid (0.57 mm/mm), while from 80 to 100° it was higher in the conoid (0.88 mm/mm) than in the anteroinferior bundle (0.77 mm/mm). InterpretationThe coracoclavicular ligament complex demonstrated a high stress-strain concentration during simulated passive shoulder abduction. Additionally, it was shown that the acromioclavicular ligament plays an important role in joint restraint during passive horizontal adduction, changing the primary role with the trapezoid and conoid at different motion intervals.

A Novel and Open Classification Emphasizing on Osteoligamentous Complex for Distal Clavicle Fractures.

Current X-ray-based classification methods cannot describe all distal clavicle fracture (DCF) patterns, especially the osteoligamentous injury pattern of DCFs. We aimed to develop a novel classification based on the osteoligamentous injury pattern of the DCFs and investigated its reliability. All DCFs from January 2017 to January 2022 were respectively screened and 45 cases (mean age 20-78; male 31, female 14) met the including criteria and were enrolled. Based on their Zanca view X-ray radiograph and three-dimensional CT construction images, we analyzed the osteoligamentous injury pattern of each case, particularly the acromioclavicular (AC) and coracoclavicular ligaments and their bone attachment. Then we developed a novel classification method, five types in total, sorting all DCFs according to their lesion manifestations of osteoligamentous complex. Also, we investigated the inter- and intra-observer reliability using kappa value. A novel classification method for DCF was developed, manifesting the avulsion or rupture of conoid and trapezoid ligaments, and involvement of AC joint. Forty-five cases of DCFs were included in this study. Among them, 11 (24.4%) were Type 1 fracture, three (6.7%) cases were Type 2, six cases (13.3%) were Type 3, 21 (46.7%) were Type 4, four (8.9%) were Type 5. Kappa values for inter-observer agreement were 0.57 after first evaluation and 0.61 after second evaluation. Intra-observer agreement was 0.72 for experienced shoulder specialist and 0.63 for radiologist. This new classification method is reliable to use, supplementary to current classification systems, and emphasizes on the osteoligamentous complex injury when opting for the treatment.

Comparison of the Hook Plate versus TightRope System in the Treatment of Acute Type III Acromioclavicular Dislocation

The objective of this study is to compare the effectiveness of the clavicular hook plate (HP) technique and the minimally invasive coracoclavicular (CC) fixation with a TightRope (MITR) procedure in treating acute unstable distal clavicle dislocation. MITR (minimally invasive TightRope) group had 21 patients, and the open reduction and internal fixation (HP) group included 23 patients. Researchers compared MITR and HP (hook plate) outcomes for the treatment of acute type III AC joint dislocation in a retrospective analysis. The patients were followed up at 1 3, 6, and 12 months postoperatively. Complications were analyzed such as redislocation, fractures, implant-related complications, or subacromial erosion. For the clinical outcomes, the visual analog scale (VAS) (0: no pain, 10: worst possible pain), Constant-Murley score (CMS) (100: no pain, 0: maximum pain), the average satisfaction score with their current shoulder function (range: 0-10), and the University of California at Los Angeles Shoulder score (UCLA) (>27 good/excellent <27 fair/poor) were recorded at the last follow-up. There were 21 sufferers in the MITR group, which comprises 19 males and 2 females and 23 individuals in the HP group (20 men and 3 women), with average ages of 43.9 and 39.2, respectively. Age, sex, laterality, and the interval between injury and surgery did not significantly differ between the two groups (0.357, 0.792, 0.432, and 0.55, respectively). No statistically significant difference was found between the groups in terms of the VAS score and CMS score at one year postoperatively. The mean CCD at the initial trauma and last follow-up was not significantly different between the MITR and HP groups (p=0.365, p=0.412 respectively). For treating acute type III AC dislocations, the minimally invasive TightRope (MITR) system and the hook plate technique were great options. However, the minimally invasive TightRope system showed further benefits such as reduced reoperation for implant removal and reduced risk of subacromial distal clavicle osteolysis.

Comparing the Efficacy of Anatomical Locked Plate Fixation with Coracoclavicular Ligament Augmentation to Hook Plate Fixation in Treating Distal Clavicle Fractures.

Hook plate fixation is the traditional method for treating distal clavicle fractures. However, in recent years, locked plate applications have emerged as a promising treatment method. This study aimed to compare the short- and mid-term clinical efficacy of anatomical locked plate fixation with coracoclavicular ligament augmentation using anchor nails to that of hook plate fixation in treating distal clavicle fractures. This was a retrospective single-center cohort study investigating patients with distal clavicle fractures treated between January 2016 and February 2019 in Zhongnan Hospital of Wuhan University. Fifty-nine eligible patients who underwent either anatomical locked plate fixation with coracoclavicular ligament augmentation using anchor nails (LPF&CLA group; 20 patients) or clavicle hook plate fixation (CHPF group; 39 patients) were included. The visual analog scale (VAS) and Constant-Murley shoulder scores were used to assess shoulder function. In addition, the coracoclavicular distance between the affected and unaffected shoulders (ΔCC distance) was measured to assess the reduction. Patients were followed up at 3 months, 6 months, and 1 year postoperatively. The comparisons between the two groups were made using Student's t-test, chi-square test, or Fisher's exact test, if appropriate. Preoperative VAS scores were similar in both groups. At 3- and 6-month follow-up, the VAS score was significantly higher in the CHPF group than in the LPF&CLA group. In contrast, the Constant-Murley shoulder score was significantly lower in the CHPF group than in the LPF&CLA group. When the hook plates were removed, there was no statistical difference in both VAS (0.2 ± 0.4 in LPF&CLA group vs. 0.5 ± 0.5 in CHPF group, p= 0.05) and Constant-Murley shoulder (96.1 ± 3.1 in LPF&CLA group vs. 93.8 ± 5.2 in CHPF group, p= 0.08) scores at the last follow-up. Postoperatively, the ΔCC distance was 2.37 ± 1.93 mm in the LPF&CLA group and -1.56 ± 1.34 mm in the CHPF group. One year after surgery, ΔCC distance increased to 3.96 ± 1.17 mm in the LPF&CLA group and to -0.89 ± 1.39 mm in the CHPF group. For distal clavicle fractures in which the coracoclavicular ligament is disrupted, anatomical locked plate fixation with coracoclavicular ligament augmentation achieved better functional recovery and less pain than hook plate fixation at the 6-month follow-up. However, the hook plate provided better reduction throughout the follow-up period and shoulder pain could be relieved using removal surgery. Therefore, locked plates with coracoclavicular ligament augmentation favors post-surgery pain relief while harvesting similar functional outcomes to hook plate fixation.

Biomechanical Efficacy of Tape Cerclage as an Augment or Stand-alone for Coracoclavicular Ligament Reconstruction

Background: Loss of initial reduction of the acromioclavicular joint after coracoclavicular (CC) ligament reconstruction remains a challenge for various repair techniques. Previous studies using polydioxanone suture cerclage augments for CC ligament reconstruction demonstrated poor clinical and biomechanical outcomes. Tape-style sutures have recently gained popularity because of their added stiffness and strength relative to traditional sutures. These tape cerclage systems have yet to be biomechanically studied in CC ligament reconstruction. Purpose: To determine the efficacy of a tape cerclage system as an augment to CC ligament reconstruction. Study Design: Controlled laboratory study. Methods: A total of 24 human cadaveric shoulders were utilized. These were divided into 4 repair groups: anatomic CC ligament reconstruction (ACCR), ACCR with a tape cerclage augment (ACCR + C), tendon graft sling with a cerclage augment (TGS + C), or tape cerclage sling alone (CS). The repairs underwent superior/inferior cyclic loading to evaluate for displacement. Specimens were visually inspected for cortical erosion by the tape cerclage after cyclic loading. Finally, the constructs underwent superior plane load-to-failure testing. Results: Less displacement after cyclic loading was observed in the ACCR + C (mean ± SD, 0.42 ± 0.32 mm), TGS + C (0.92 ± 0.42 mm), and CS (0.93 ± 0.39 mm) groups as compared with the ACCR group (4.42 ± 3.40 mm; P = .002). ACCR + C (813.3 ± 257.5 N), TGS + C (558.0 ± 120.7 N), and CS (759.5 ± 173.7 N) demonstrated significantly greater load at failure relative to ACCR (329.2 ± 118.2 N) (P < .001). ACCR + C (60.88 ± 17.3 N/mm), TGS + C (44.97 ± 9.15 N/mm), and CS (54.52 ± 14.24 N/mm) conferred greater stiffness than ACCR (27.43 ± 6.94 N/mm) (P = .001). No cortical erosion was demonstrated in any specimen after cyclic loading. Conclusion: In a cadaveric model at time zero, repairs utilizing a tape cerclage system confer significantly greater load to failure and stiffness, as well as decreased displacement with cyclic loading, when compared with traditional ACCR repair. Clinical Relevance: Tape cerclage augmentation may provide a useful augment for CC ligament reconstruction.

Reconstruction of the Acromioclavicular Joint Using a Double Augmentation With Hamstrings Tendon and Dermal Graft

The purpose of this article is to describe a technique to restore both vertical and horizontal stability using an augmentation of the acromioclavicular ligament complex (ACLC) and coracoclavicular (CC) ligaments with the combination of synthetic and biological support. Our technique introduces a modification in the surgical procedure for acromioclavicular (AC) joint dislocations; it provides the use of biological supplements not only during the repair of the CC ligaments but also when the ACLC is restored due to the use of a dermal patch as an augmentation allograft after the use of a horizontal cerclage. The main purpose of this technique is to replicate the anatomy and functionality of the native ligaments that stabilize the AC joint to improve both clinical and functional results.

Bifocal Stabilisation of Acute Acromioclavicular Joint Dislocation using Suture Anchor and Temporary K-Wires: A Retrospective Analysis.

The acromioclavicular joint (ACJ) is a major link connecting the upper limb to the torso. The acromioclavicular and coracoclavicular (CC) ligaments help in stabilising the joint. We feel it is prudent to address both these ligament injuries, to achieve optimum result. This study was undertaken to analyse the results of a simple frugal surgical technique we used to deal with this injury considering stabilisation for both these ligaments. In this retrospective study, skeletally mature patients with Type III, IV or V ACJ dislocations who underwent open reduction and stabilisation of the joint with temporary K-wires, repair of the capsule and augmentation of CC ligaments with suture anchors were included. Clinico-radiological and functional outcome was evaluated. Functional assessment of the upper limb was analysed using the Disabilities of Arm, Shoulder, and Hand Score (DASH), Constant shoulder score (CSS) and Oxford shoulder score (OSS). Clinical and radiological evaluation of the 32 patients who had completed two years from the index surgery, was done. Out of the 37 patients included initially, five were lost in follow-up. Majority of the subjects included were males and type V was the most common injury. Mean pre-operative CC distance on the affected side was 13.92±4.94mm. In the immediate post-operative radiograph, it was 7.63±2.08mm and in the final follow- up was 9.36±2.75mm. Measurements were taken by two independent investigators and inter, and intra-observer reliability were analysed by Interclass correlation coefficient. Excellent functional outcome was noted despite the 1.81±1.50mm average loss of correction. At final follow-up, mean DASH score was 4.67±4.18, Oxford shoulder score was 44.06±2.44 and Constant shoulder score was 86.37±5.81. The severity of the injury had no significant effect on the functional outcome post our method of stabilisation and rehabilitation. Bifocal fixation restores the multidirectional stability of the disrupted ACJ. Adequate radiological reduction, good functional outcome and simplicity of execution make this technique an undemanding one for use in regular practice.

Comparing the Anatomical Landmarks Versus the Coracoid-Based Landmarks Techniques for Coracoclavicular Stabilization After High-Grade Acromioclavicular Injury: A Biomechanical Study.

In acute high-grade acromioclavicular (AC) joint injuries, the aim of treatment is robust reduction and stabilization of the joint. The anatomical landmarks method is most commonly used for stabilization, but loss of reduction often occurs because of the suture tunnels. The purpose was to evaluate and compare the stability of coracoclavicular (CC) stabilization using the anatomical landmarks and coracoid-based landmarks techniques in treating a high-grade AC joint injury. It was hypothesized that stabilization using coracoid-based landmarks would provide better stability. Controlled laboratory study. Twenty fresh-frozen cadaveric shoulders (8 male and 2 female pairs) were randomized into 2 operative technique groups: 10 shoulders in the anatomical landmarks group and 10 shoulders in the coracoid-based landmarks group. The CC ligaments and AC capsule were cut at the midlevel, and CC stabilization and AC capsule repair were performed. For the anatomical landmarks technique, two 2.5-mm clavicular tunnels were created at 25 and 45 mm from the AC joint, while for the coracoid-based landmarks technique, two 2.5-mm clavicular tunnels were drilled using the medial and lateral borders of the coracoid base to choose the tunnel sites. Before injury creation and after stabilization, each shoulder underwent a loading force of 70 N in the superior and anteroposterior directions, and the displacement distance and stiffness were compared between the 2 techniques using the paired t test. The mean difference in displacement before and after stabilization was higher in the anatomical landmarks technique than the coracoid-based landmarks technique (1.82 ± 3.52 vs -0.18 ± 4.78 mm in the superior direction and 7.47 ± 9.35 vs 1.76 ± 3.91 mm in the anteroposterior direction), but none of the differences in displacement or stiffness were statistically significant between the groups. No significant biomechanical differences in displacement or stiffness were seen between the anatomical landmarks technique and the coracoid-based landmarks technique. Either stabilization technique can be utilized for repair of the CC ligaments in an acute AC injury setting.

Clinical and radiologic outcomes of the modified phemister procedure with coracoclavicular ligament augmentation using mersilene tape versus hook plate fixation for acute acromioclavicular joint dislocation

BackgroundThe clinical superiority of surgical treatment for acromioclavicular (AC) joint dislocation remains controversial. The aim of this study was to compare the clinical and radiological outcomes of the modified Phemister procedure with CC ligament augmentation using Mersilene tape to those of hook plate fixation for acute AC joint dislocation.MethodsIn this study, patients who received modified Phemister surgery with CC ligament augmentation using Mersilene tape (PM group) or hook plate fixation (HK group) for acute unstable AC joint dislocation with a minimum 5-year follow-up period were retrospectively reviewed. The clinical outcomes were evaluated according to blood loss during surgery, surgical duration, visual analogue scale (VAS), Constant-Murley score (CMS), University of California at Los Angeles (UCLA) shoulder rating scale, and the occurrence of complications. Radiological outcomes were assessed from radiographs according to multiple parameters, including CC distance maintenance, acromion osteolysis, and the presence of distal clavicle osteolysis.ResultsA total of 35 patients completed follow-up for more than 5 years and were analyzed in this study (mean = 74.08 months). There were 18 patients in the PM group and 17 in the HK group. The PM group exhibited similar improvement in functional outcome to the HK group. Regarding radiological outcomes, the HK group had a superior performance in terms of CC distance maintenance, of statistical significance (CCDR: 94.29 ± 7.01% versus 111.00 ± 7.69%, p < 0.001) after a one-year follow-up period. However, there were 4 cases of acromion osteolysis and 2 cases of distal clavicle osteolysis in the HK group.ConclusionHook plate fixation was found to be superior to the modified Phemister technique with CC ligament augmentation using Mersilene tape in terms of CC distance maintenance, but there was no significant difference in the functional outcome after 5 years of follow-up. Both surgical methods are reliable options for the treatment of acute AC joint dislocation. Modified Phemister surgery with CC ligament augmentation using Mersilene tape is a relatively lower-cost option for acute AC joint dislocation without the need of a second surgery for implant removal.