Article

Ligamentous anatomy of the distal clavicle

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Abstract

We describe the insertional variations of supporting ligaments of the acromioclavicular joint, especially with respect to gender. We analyzed 41 cadaveric clavicles (22 female and 19 male) with attached ligaments. The distance between the insertion of the trapezoid ligament and the distal end of the clavicle was not significantly different between sexes, although that of the conoid ligament and the mean anteroposterior width of the distal clavicle was significantly greater in men. Although there are significant sex-related differences in the insertional distances of the CC ligaments, resection of less than 11.0 mm should not violate the trapezoid ligament and less than 24.0 mm should not violate the conoid ligament in either sex in 98% of the general population. Resection of more than 7.6 mm of the distal clavicle in men and 5.2 mm in women, performed by an arthroscopic approach, may violate the superior acromioclavicular ligament.

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... The trapezoid ligament is larger and roughly quadrilateral in shape, and it inserts onto the distal clavicle along the trapezoidal line (trapezoidal ridge), spanning a region 1.5-3.0 cm from the joint line (29,30). The conoid ligament is conical in shape, nearly vertical, and located posteromedial to the trapezoid ligament. ...
... The conoid ligament is conical in shape, nearly vertical, and located posteromedial to the trapezoid ligament. Its fibers twist as they extend superiorly to insert at the conoid tubercle and adjacent clavicle, spanning 3-5 cm medial to the joint line (29,30). The trapezoid ligament restrains posterior clavicular displacement and AC compression, while the conoid ligament is principally responsible for vertical stability, restraining superior migration of the clavicle (3,18). ...
Article
The acromioclavicular joint is an important component of the shoulder girdle; it links the axial skeleton with the upper limb. This joint, a planar diarthrodial articulation between the clavicle and the acromion, contains a meniscus-like fibrous disk that is prone to degeneration. The acromioclavicular capsule and ligaments stabilize the joint in the horizontal direction, while the coracoclavicular ligament complex provides vertical stability. Dynamic stability is afforded by the deltoid and trapezius muscles during clavicular and scapular motion. The acromioclavicular joint is susceptible to a broad spectrum of pathologic entities, traumatic and degenerative disorders being the most common. Acromioclavicular joint injury typically affects young adult males and can be categorized by using the Rockwood classification system as one of six types on the basis of the direction and degree of osseous displacement seen on conventional radiographs. MRI enables the radiologist to more accurately assess the regional soft-tissue structures in the setting of high-grade acromioclavicular separation, helping to guide the surgeon's selection of the appropriate management. Involvement of the acromioclavicular joint and its stabilizing ligaments is also important for understanding and classifying distal clavicle fractures. Other pathologic processes encountered at this joint include degenerative disorders; overuse syndromes; and, less commonly, inflammatory arthritides, infection, metabolic disorders, and developmental malformations. Treatment options for acromioclavicular dysfunction include conservative measures, resection arthroplasty for recalcitrant symptoms, and surgical reconstruction techniques for stabilization after major trauma.
... En otro estudio anatómico, Stine y Vangsness comprobaron que la inserción de los mismos en la clavícula comenzaba a 3,5 mm y a 2,8 mm de la superficie articular del acromion y que, si se resecaban más de 4 mm del acromion y 6 mm de la clavícula, se desinsertaban los ligamentos acromioclaviculares en la mayoría de los hombros estudiados 6 . Renfree et al. observaron en su estudio que una mínima resección clavicular de 2,6 mm en hombres y 2,3 mm en mujeres podía afectar a los ligamentos acromioclaviculares superiores de algunos individuos 20 . Por lo tanto hay que evitar resecciones importantes de la clavícula y del acromion para impedir que se pueda producir una desinserción del LACS. ...
... superficie articular y termina, por término medio, a 29 mm de la misma 19 . No hay diferencias significativas entre hombres y mujeres en cuanto a la distancia de inserción de los mismos desde la superficie articular 20 . ...
Article
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In order to treat acromioclavicular disorders, one should know the anatomy of the joint and the nearby structures that influence it. This knowledge is necessary to know how to diagnose what may be the cause of the disorder, to assess which are the structures that must be rebuilt after a joint injury, and to know which structures should be respected during the surgery. In this article, the bony anatomy, the anatomy and function of the ligaments that act on this joint, biomechanics, and the pathophysiology of the acromioclavicular joint is presented.
... 8 The most lateral edge of the superior AC ligament inserts anywhere from 1 mm to 3.5 mm medial to the edge of the joint on the distal clavicle. 10,11 The distance from the articular surface of the distal clavicle to the most lateral aspect of the trap-ezoid and conoid ligaments are 16.7 mm in men and 16.1 mm in women and 33.5 mm in men and 28.9 mm in women, respectively. 10 The normal CC interspace is 11 mm to 13 mm ( Figure 1C) 12,13 ; this is measured on an anteroposterior (AP) radiograph and is the distance between the superior margin of the coracoid and the inferior margin of the clavicle. ...
... 10,11 The distance from the articular surface of the distal clavicle to the most lateral aspect of the trap-ezoid and conoid ligaments are 16.7 mm in men and 16.1 mm in women and 33.5 mm in men and 28.9 mm in women, respectively. 10 The normal CC interspace is 11 mm to 13 mm ( Figure 1C) 12,13 ; this is measured on an anteroposterior (AP) radiograph and is the distance between the superior margin of the coracoid and the inferior margin of the clavicle. ...
... There is no clear consensus in the literature regarding the exact amount of distal clavicle resection required to achieve symptomatic relief from ACJ pathology, whilst maintaining the stability of the joint. However, both cadaveric and clinical studies support that the resection length used in this study, namely 10 mm, will provide adequate pain relief, 5,18 whilst maintaining the integrity of the nearby coracoclavicular ligaments, 6 with these ligaments being the primary biomechanical stabilizers of the ACJ. ...
Article
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Background Distal clavicle excision for acromioclavicular joint (ACJ) pathology is currently the mainstay of surgical management in patients with symptoms refractory to nonoperative treatment. There have been few high quality studies outlining the efficacy of arthroscopic excision of the distal clavicle as a single procedure in patients with isolated disease. Aim To characterize function and pain outcomes in patients undergoing arthroscopic distal clavicle excision by utilizing stringent inclusion criteria to isolate ACJ pathology. Methods Prospective data collection was undertaken with a minimum two year follow-up of 59 patients undergoing arthroscopic distal clavicle excision for ACJ osteoarthritis or distal clavicle osteolysis. Stringent eligibility criteria were applied to each patient. Data collection consisted of demographic data, clinical assessment of range of motion, and patient-reported outcome measures (PROMs), utilizing the standardized Shoulder Pain and Disability Index (SPADI) and the Visual Analogue (VAS) score to characterize pain. Furthermore, time to return to work and sport and a subjective measure of how ‘normal’ the shoulder felt were assessed. Data was recorded preoperatively, and at six, 12, and 24 months postoperatively. Statistical analysis was conducted utilizing institutional support. Results Statistically significant improvements in range of motion measurements (abduction, forward elevation and external rotation), and PROMs (SPADI and VAS scores) were reported. VAS scores reduced from an average of 8.20 preoperatively to 3.39 (P < .001), 2.13 (P < .001) and 1.36 (P < .001) at 6, 12, and 24 month follow-up, respectively. Similarly, SPADI scores reduced from an average of 62.65 preoperatively to 19.96 (P < .001), 12.6 (P < .001), and 6.13 (P < .001) at 6, 12, and 24 months, respectively. The majority of patients were able to return to sport and work, within an average time of 1.72 and 3.02 months. Conclusion In patients who presented with isolated ACJ pathology, arthroscopic distal clavicle excision, as a single procedure, results in statistically significant improvements in PROMs and functional outcomes.
... The trapezoid ligament is located 2-3 cm medial to the AC joint, and the conoid ligament is located 4-4.5 cm medial to the AC joint. [5] Neer has given a classification of the distal end of clavicle fractures in three types based on the integrity of coracoclavicular ligaments and the degree of involvement of acromioclavicular joint. [6] Later, Craig added two additional subtypes to the original classification. ...
Article
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Objectives Lateral end of clavicle fractures is associated with coracoclavicular ligament disruption and, hence, poses a surgical challenge for the management. Surgical techniques already described have high failure rates and hardware-related complications. The objective of the study is to assess the clinical and radiological outcome of the novel surgical technique of arthroscopic coracoclavicular stabilization and indirect anatomical reduction of the lateral end of clavicle fracture using FiberWire and FiberTape. Materials and Methods We conducted a retrospective review of 15 consecutive patients with displaced, unstable Neer Type II and V distal clavicle fractures who underwent this surgical technique from 2016 to 2020. Primary outcome variables were radiographic union, patient satisfaction, and post-operative shoulder function. Pre-operative and post-operative University of California, Los Angeles (UCLA), and American Shoulder and Elbow Surgeons (ASES) scores were compared. Secondary outcome variables included intraoperative complications, post-operative complications, and time to radiographic union. Results In our study, 12 were male patients and three female patients, with a mean age of 43 years. The mean post-operative follow-up period was 23 months. Results were satisfactory in all 15 cases, all 15 were had excellent as per UCLA and ASES score. All fractures healed within a mean period of 6 weeks. Only one patient had developed malunion due to over-tightening of FiberWire, although his functional outcome was not compromised with this. Conclusion We present a novel surgical technique for fixing displaced distal lateral clavicle with arthroscopic coracoclavicular stabilization with FiberWire and FiberTape that resulted in a 100% union rate and excellent clinical outcomes with minimal complications.
... Surgical Procedure for the Novel Double Endobutton Technique First, two 1.5-2.0-cm marks were made 2 cm medial to the distal end of the clavicle and 4 cm medial to the distal end of the clavicle, which was consistent with anatomical attachment landmarks of the trapezoid (women, 1.6 to 2.7 cm and men, 1.7 to 2.8 cm) and conoid ligaments (women, 2.9 to 4.4 cm and men, 3.4 to 5.0 cm) 4,24 . ...
Article
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Objective To reconstruct the acromioclavicular (AC) joint using an adjusted closed‐loop double Endobutton technique via a guiding locator that was applied using three‐dimensional (3D) printing technology. At the same time, the reliability and safety of the novel double Endobutton (NDE) were tested by comparing the biomechanics of this technique with the TightRope (TR) approach. Methods This retrospective study was conducted between January 2017 and January 2019. The Department of Anatomy at Southern Medical University obtained 18 fresh‐frozen specimens (8 left and 10 right; 12 men and 6 women). First, the guiding locators were applied using 3D printing technology. After preparation of materials, specimens were divided into an NDE group, a TR group, and a normal group. In the NDE and TR groups, the navigation module was used to locate and establish the bone tunnels; after that, the NDE or TR was implanted. However, the Endobuttons were fixed while pressing the distal clavicle downwards and the length of the loop could be adjusted by changing the upper Endobutton in the NDE group while the suture button construct was tensioned and knotted after pressing down the distal clavicle in the TR. Finally, load testing in anterior–posterior (AP), superior–inferior (SI), and medial–lateral (ML) directions as well as load‐to‐failure testing in the SI direction were undertaken to verify whether the NDE or TR had better biomechanics. Results In the load testing, the displacements of the NDE and TR groups in the AP, SI, and ML direction were significantly shorter than those of the normal group (P < 0.05). In the load‐to‐failure testing, the ultimate load of the NDE and TR groups had significantly higher increases than the normal group (722.16 ± 92.04 vs 564.63 ± 63.05, P < 0.05; 680.20 ± 110.29 vs 564.63 ± 63.05, P < 0.05). However, there was no statistically significant difference between the two techniques for these two tests (P > 0.05). In the NDE group, four of six failures were a result of tunnel fractures of the coracoid, while two of six were due to suture breakage. In the TR, three failures were due to coracoid tunnel fractures, one was a result of a clavicle tunnel fracture, and the rest were due to suture breakage. In the normal group, half of the failures were a result of avulsion fractures of the conical ligament at the point of the coracoid process, and the other three were due to rupture of the conical ligament, fracture of the distal clavicle, and fracture of the scapular body. Conclusion As for the TR technique, the stability and strength of the AC joint were better in patients who underwent reconstruction using the NDE technique than in the intact state.
... These holes refer to anatomical attachment landmarks of the trapezoid (women, 16 to 27 mm and men, 17 to 28 mm) and conoid ligaments (women, 29 to 44 mm and men, 34 to 50 mm). 13 ...
Article
Background: Although many techniques are used to treat the Acromioclavicular (AC) joint dislocations, minimal invasive or arthroscopic coracoclavicular ligament reconstructions became popular recently. In this study authors compared the biomechanical results of double versus triple button reconstruction techniques. Methods: Three-dimensional solid modeling of the shoulder girdle was carried out using virtual finite element modeling. AC joint dislocation was applied to the reference model and these models were repaired by double and triple button techniques respectively. Maximum equivalent stresses on buttons and sutures as well as displacements and reaction forces on AC joint were evaluated. Results: Triple button model was more stable during flexion and abduction when compared with double button technique. Conclusion: Mimicking conoid ligament has a crucial mission more particularly against resistance during frontal plane actions, but the absence of the trapezoid ligament causes increasing the posterior displacement of the distal clavicle during the flexion of GH joint.
... Nevertheless, we strongly disagree with the comment that the site of ossification is suspicious to be related with ligament calcification because of its' "too medial" localization, although it is apparent that the site of ossification is on the trajectory of conoid ligament. From a scientific point of view, it is clearly stated that the mean length from the end of the clavicle or AC joint to the most medial insertion of the conoid ligament of CC complex is found 49.7 ± 5.4 mm in men and 44.4 ± 4.4 in women in one of the two well-respected studies, 12 and 46.3 mm in the other one. 13 So, both visually and scientifically, there is no doubt in the diagnosis of ligament calcification, unless the authors have "any other" differential diagnosis for the finding. ...
... Trapezoid bağ, eklemden yaklaşık 2 cm, konoid bağ ise yaklaşık 4 cm mediyaldedir. [13] Distal klavikula kırıkları, kırık yerleşimine göre sınıflanır. KK bağ lateralinde kalan ve ekleme uzanmayan kırıklar Tip I, KK bağ lateralinde kalan ve ekleme uzanan kırıklar Tip III olarak sınıflanır. ...
... To achieve better stability, the distance of the insertion site of the clavicle and acromion should be approximate to the anatomical position of 5.2 mm (women) and 7.6 mm (men). 23 Future studies are warranted to explore the long-term therapeutic results of this technique. ...
Article
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Background The aim of this study was to evaluate the therapeutic effect of autogenous semitendinosus graft and endobutton technique, and compare with hook plate in treatment of Rockwood type III acromioclavicular (AC) joint dislocation. Methods From April 2012 to April 2013, we treated 46 patients with Rockwood type III AC joint dislocation. Patients were randomly divided into two groups: Group A was treated using a hook plate and Group B with autogenous semitendinosus graft and endobutton technique. All participants were followed up for 12 months. Radiographic examinations were performed every 2 months postoperatively, and clinical evaluation was performed using the Constant–Murley score at the last follow-up. Results Results indicated that patients in Group B showed higher mean scores (90.3±5.4) than Group A (80.4±11.5) in terms of Constant–Murley score (P=0.001). Group B patients scored higher in terms of pain (P=0.002), activities (P=0.02), range of motion (P<0.001), and strength (P=0.004). In Group A, moderate pain was reported by 2 (8.7%) and mild pain by 8 (34.8%) patients. Mild pain was reported by 1 (4.3%) patient in Group B. All patients in Group B maintained complete reduction, while 2 (8.7%) patients in Group A experienced partial reduction loss. Two patients (8.7%) encountered acromial osteolysis on latest radiographs, with moderate shoulder pain and limited range of motion. Conclusion Autogenous semitendinosus graft and endobutton technique showed better results compared with the hook plate method and exhibited advantages of fewer complications such as permanent pain and acromial osteolysis.
... The trapezoid ligament varied from 0.8 cm to 2.5 cm both in length and in width, while the conoid ligament varied from 0.7 cm to 2.5 cm in length and from 0.4 cm to 0.95 cm in width. Several studies (6)(7)(8)(9) have shown the center of the trapezoid and the conoid ligament insertion to be located 2.5 cm and 4.6 cm from the lateral edge of the clavicle, respectively (Fig. 1). The lateral edges of the trapezoid and the conoid ligament origins were located 11.8 mm and 25.3 mm from the distal end of the clavicle, respectively. ...
Article
Acromioclavicular (AC) joint instability is a common source of pain and disability. The injury is most commonly a result of a direct impact to the AC joint. The AC joint is surrounded by a capsule and has an intra-articular synovium and an articular cartilage interface. An articular disc is usually present in the joint, but this varies in size and shape. The AC joint capsule is quite thin, but has considerable ligamentous support; there are four AC ligaments: superior, inferior, anterior and posterior. The coracoclavicular (CC) ligament complex consists of the conoid and trapezoid ligaments. They insert on the posteromedial and anterolateral region of the undersurface of the distal clavicle, respectively. The coracoid origin of the trapezoid covers the posterior half of the coracoid dorsum; the conoid origin is more posterior on the base of the coracoid. Several biomechanical studies showed that horizontal stability of the AC joint is mediated by the AC ligaments while vertical stability is mediated by the CC ligaments. The radiographic classification of AC joint injuries described by Rockwood includes six types: in type I injuries the AC ligaments are sprained, but the joint is intact; in type II injuries, the AC ligaments are torn, but the CC ligaments are intact; in type III injuries both the AC and the CC ligaments are torn; type IV injuries are characterized by complete dislocation with posterior displacement of the distal clavicle into or through the fascia of the trapezius; type V injuries are characterized by a greater degree of soft tissue damage; type VI injuries are inferior AC joint dislocations into a subacromial or subcoracoid position. The diagnosis of AC joint instability can be based on historical data, physical examination and imaging studies. The cross body adduction stress test has the greatest sensitivity, followed by the AC resisted extension test and the O'Brien test. Proper radiographic evaluation of the AC joint is necessary. The Zanca view is the most accurate view for examining the AC joint. The axial view of the shoulder is important in differentiating a type III AC joint injury from a type IV injury.
... Resection of more than 7.6 mm of the distal clavicle in men and 5.2 mm in women, performed using an arthroscopic approach, may violate the SACL. 9 We find it hard to accurately determine intraoperatively the amount of bone to resect during the indirect subacromial technique and, as reported in the literature, 3,5,6 we have had previous cases where the resection was insufficient, especially on the superior aspect of the distal clavicle just beneath the SACL. These patients have had persistent postoperative pain and positive crossover test result, requiring revision surgery. ...
Article
Bursal and superior direct arthroscopic distal clavicle resection techniques exist. An indirect transarticular distal clavicle resection (TADCR) technique, in which the bone resection is performed directly through the acromioclavicular joint (ACJ), is presented. With the arthroscope in the lateral portal and viewing at the ACJ, the TADCR begins by inserting a needle into the ACJ to determine the angle of entrance (a 5-mm skin incision directly over the mid portion of the ACJ is made). Then, with a No. 11 blade, a 4- to 5-mm incision, which is just large enough to ensure the pass of the motorized instruments, is made in the mid portion of the superior acromioclavicular ligament (SACL) parallel to its fibers. A radio frequency probe is inserted, and the ACJ's soft tissues are excised, taking care not to damage the SACL. Then, the saver is introduced to clean up the soft tissue's debris. Finally, a 4.0-mm oval burr is inserted and, with a fan-shaped motion, bone is resected from clavicle and acromion without damaging the superior ligament. The TADCR is an easy technique that produces consistent bone resection, sparing the SACL.
... Earlier publications focused on specific length and measurements for the insertion points of the CC ligaments. [12][13][14] Rios and colleagues 15 performed an anatomic study that found similar absolute measurements of the ligament insertion point from the lateral end of the clavicle; however, they divided these by the clavicular length to establish a ratio, which was very consistent across all their specimens. The average ratios for the conoid and trapezoid tunnels were 0.24 and 0.17 respectively. ...
Article
Acromioclavicular (AC) dislocations occur frequently in the military population. Most are successfully treated nonoperatively. However, military requirements include more demanding use, resulting in an increased failure rate of conservatively managed AC injuries. Surgical management is indicated for injuries that fail nonoperative treatment, high-grade injuries, and in those patients at high risk for failure of conservative management. No surgical technique is clearly superior but anatomic reconstruction is a consistent procedure with good biomechanical support and growing positive clinical data. There is a substantial risk of failure or complication so the surgeon must approach this injury with meticulous attention.
Chapter
The authors present an accurate description of the different anatomical structures of the shoulder, including the glenohumeral joint (capsoligamentous structures, glenoid, glenoid labrum, and humeral head), the acromioclavicular joint, the extraarticular/subacromial space (acromion and spine of the scapula, coracoacromial ligament, coracoid, coracohumeral ligament, synovial bursae, rotator cuff muscles and tendons, long head of biceps, lastissimus dorsi muscle), and neurovascular structures, focusing on the relationships between anatomic features and the most common arthroscopic shoulder portals and procedures.KeywordsShoulderAnatomyArthroscopyAnatomical description
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There has been a rapid evolution in best practice management of acromioclavicular (AC) joint injuries. AP, Zanca, scapular Y, and dynamic axillary radiographic views provide optimal visualization of the joint and may assess for the presence of horizontal AC instability. Severity of AC joint pathology is classified according to the 6-tier Rockwood scoring system. Over 160 surgical techniques have been described for AC joint repair and reconstruction in the last decade; as a result, determining the optimal treatment algorithm has become increasingly challenging secondary to the lack of consistently excellent clinical outcomes.
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Distal clavicle excision (DCE) for acromioclavicular (AC) joint primary osteoarthritis and post-traumatic arthritis has been shown to have good to excellent outcomes. However, there are studies that report significant rates of residual AC joint pain and distal clavicle instability after open and arthroscopic techniques. We describe a surgical technique for management of AC joint primary osteoarthritis, post-traumatic arthritis, and revision DCE that involves DCE with ligament reconstruction and tendon interposition arthroplasty. It provides distal clavicle stability and can theoretically reduce residual AC joint pain secondary to acromial abutment after DCE.
Chapter
The scapula, clavicle, and complex of associated joints provide an intricate linkage between the axial and appendicular skeleton. Common scenarios occur in which injury to the shoulder girdle and thoracic attachments can lead to chronic pain, weakness, dysfunction, and overall decreased quality of life. For this reason, there must be a high index of suspicion and a thoughtful treatment plan for shoulder girdle injury in association with chest wall trauma. Effective diagnosis and treatment require proper imaging and careful consideration of surgical indications. Surgical intervention, when indicated, has a low complication rate and results in superior functional outcomes. Concurrent treatment of rib, clavicle, and scapula fractures in the same surgical setting is feasible and should be considered whenever possible. Interdisciplinary communication is necessary to ensure optimal treatment of complex chest wall trauma with multiple injuries.KeywordsScapulaClavicleShoulder girdle injuryFractureChest wallForequarter lateral implosion
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Résumé L’arthropathie acromioclaviculaire est une pathologie douloureuse de la ceinture scapulaire, peu souvent diagnostiquée chez les sportifs et pouvant provoquer un handicap sévère. Le diagnostic précoce peut améliorer le pronostic fonctionnel en réduisant le nombre d’athlètes qui doivent abandonner définitivement la compétition. Les auteurs présentent un cas d’arthropathie acromioclaviculaire initialement traité comme une pathologie de la coiffe des rotateurs.
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Introduction The surgical treatment of the proximal humerus fractures is challenging because of various presentations, especially in osteoporotic bones. The use of fixed-angle locked plates combined with grafts increases the fixation stability and healing rate. This study aims to describe a novel option of autogenous bone graft from the distal clavicle in the treatment of the proximal humerus fracture. Materials and Methods This is a descriptive study of a novel technique including patients undergoing surgical treatment of the proximal humerus fracture with locked plates and autograft from the distal clavicle. Results A total of 3 female patients underwent treatment in the last year, and there are no complications reported. All fractures remained stable without varus collapse of the humeral head. Conclusion We are the first to describe the use of the distal clavicle as an option of autograft for the treatment of the proximal humerus fractures. This technique has low morbidity and complexity, easy reproduction and low cost and can be harvested in the same donor region as the operative site.
Chapter
The conditions of the acromioclavicular joint (AC) including traumatic and degenerative pathologies are some of the most common causes of a painful shoulder. However the involvement of this joint is underestimated, which is nicknamed for this reason “the forgotten articulation”.
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Plate fixation has recently gained popularity among the various surgical methods used to treat Neer type II distal clavicle fractures. The use of a low-profile distal clavicle locking plate is logically considered a better option when there is no significant difference in the fixation strength between insertions of 3.5- and 2.7-mm diameter screws. Therefore, the purpose of this biomechanical study was to investigate any differences in fixation strength among varying sizes of screws that are used to treat distal clavicle fractures. The study was performed with 20 paired shoulder girdles from 10 fresh frozen cadavers. To create a type IIA fracture of Neer classification, osteotomy was performed perpendicularly to the longitudinal axis of the clavicle at the medial end point of the conoid ligament. Two custom-made fixtures designed to be attached to both upper and lower sides of the Instron were fabricated for the evaluation. The mean maximum pull-out strength for fixation using 3.5-mm diameter screws was 241.9 ± 67.8 N, whereas the mean pull-out strength in fixation with 2.7-mm diameter screws was 228.1 ± 63.0 N. There was no statistically significant difference between the two groups. Distal fragment fixation with distal clavicle locking plates using two 2.7-mm diameter screws showed comparable biomechanical pull-out strength at the time-zero setting to fixations with a hook plate using two 3.5-mm diameter screws. Therefore, the fixation of the distal fragment with a low-profile plate and 2.7-mm screws may be preferred as an alternative option if the distal fragment of the fractured clavicle is not extremely small.
Chapter
Lateral clavicle fractures represent the second most common subset of clavicle fractures. While most stable injuries heal uneventfully, displaced distal clavicle fractures have a propensity for nonunion. The degree of displacement is contingent upon the fracture’s location and the integrity of the coracoclavicular ligaments. Surgical treatment options include precontoured locked plating, hook plating, dual plating, and a variety of coracoclavicular stabilization techniques. There has been no proven gold standard in operative care for a displaced distal clavicle fracture. Given that nonunions are often asymptomatic, it is important to consider not only the personality of the fracture but also the characteristics of the patient in making the decision whether or not to operate.
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Purpose (1) Identify most recent national trends in the usage of open vs. arthroscopic approaches for DCE from 2007 to 2017, (2) to identify and compare the complication rates for both approaches, and to identify patient-specific risk factors for complications, (3) to identify and compare the revision rate for both approaches and (4) to identify and compare the reimbursement of each approach. Methods The PearlDiver® database was reviewed for patients undergoing DCE from 2007 to 2017. Patients were stratified into 2 cohorts: those undergoing arthroscopic DCE (n=8933) and those undergoing open DCE (n=2295). The rate of postoperative complications within 90 days was calculated and compared. The revision rate and reimbursement of the arthroscopic and open approach were compared. Statistical analysis included chi-square testing to compare the rates of postoperative complications, and multivariate logistic regression analysis to identify risk factors for complications within 90 days. Results were considered significant at p<.05. Results The percentage of DCEs performed arthroscopically has significantly increased from 53.9% in 2007 to 69.8% in 2016, with a concomitant decrease in the use of open DCE from 46.1% in 2007 to 30.2% in 2016. The open approach was associated with significantly more postoperative complications, including a significantly greater incidence of surgical site infection (1.9% vs. 0.3%; p<.001), wound disruption (0.3% vs. 0.1%; p<.001), hematoma (0.9% vs. 0.2%; p=.001), and transfusion (0.6% vs. 0.1%; p<.001) compared to arthroscopic DCE. Several risk factors, including open approach, diabetes, heart disease, tobacco use, chronic kidney disease and female gender were identified as independent risk factors for complications following DCE. There was no significant difference in revision rate between open and arthroscopic approach (p=.126). The reimbursement of open and arthroscopic DCE procedures were comparable, with median reimbursements of 5,408and5,408 and 5,447, respectively (p=.853). Conclusion Both arthroscopic and open DCE techniques were found to have similar reimbursement amounts, with a low rate of complications, although the open technique had a higher rate of early complications such as surgical site infection. Over the study period, there was an increase in the utilization of arthroscopic DCE, while the incidence of the open technique remained constant.
Article
Background Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated. Objective of the Review To provide an evidence-based review of clavicle fracture management in the emergency department. Discussion Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults. Conclusions When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.
Chapter
The scapular girdle is an osteoligamentous ring formed by the sternoclavicular joint (SC), the clavicle, the acromioclavicular (AC) joint and the scapula. It supports and connects the upper limb to the upper body and it therefore sometimes called the shoulder superior suspensory system. Two main mechanisms of injury are encountered: a fall on the shoulder with an impact on the side or on the tip of the shoulder, or a fall on the outstretched hand Damaging forces propagate all along the girdle and several different structures of the girdle can be simultaneous injured. Therefore, injuries range from a benign AC sprain to the severe omoscapulothoracic syndrome (or side impact syndrome) that combines injuries of the scapula, clavicle and chest wall/lung due to a severe side impact. Injury to the coracoid process is rarely isolated, and a look for associated injuries (AC joint, SC joint, glenohumeral joint) is mandatory.
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Background Avulsion fracture of the coracoclavicular ligament accompanied by upward displacement of the medial fragment of the clavicle represents a unique fracture pattern, first described by Latarjet and colleagues in 1975. Due to the function of the underlying articulations and the ligaments found in the area, this fracture pattern results in a combination of horizontal and vertical instability that must be taken into consideration when treating. Several surgical techniques have been proposed but none has been proven superior. Case summary Herein, we present a Latarjet fracture of the distal clavicle treated with a single endobutton. A 45-year-old male underwent open surgical stabilization of distal clavicular fracture 15 days after trauma. After stabilization of the fracture, we applied a single endobutton, passing through the medial fragment, inferior fragment and coracoid process. The patient was observed for 14 mo postoperative, during which time he achieved union in all three fragments of the fracture and an excellent functional clinical score. Conclusion In Latarjet fracture treatment, augmentation of the coracoclavicular ligament is the most important parameter for a favorable result.
Article
PurposeNeer type II distal clavicle fractures are associated with a high rate of non-union or malunion due to impaired coracoclavicular ligament stability. The purpose of this study was to assess the clinical and radiological outcomes of arthroscopically assisted indirect osteosynthesis for type II distal clavicle fractures using a cortical suture button device.Methods Seventeen patients Neer type II fractures of the distal clavicle were treated surgically using cortical suture button fixation between 2012 and 2017. The clinical and radiological results were assessed using the American Shoulder and Elbow Surgeons Shoulder Score (ASES), Constant-Murley score and visual analogue scale (VAS) score.ResultsAnatomic reduction and bone healing were achieved in all patients at the final follow-up. The median age of the patients was 31 years (range 19–57). The mean follow-up was 25.9 months (range 14–64). The average delay before surgery was 2 days (range 1–4). At the final follow-up, the mean ASES, Constant-Murley score and VAS score were 92.6 ± 3.2 (range 84.9–96.6), 96.2 ± 2.4 (range 92–100) and 0.47 ± 0.51 (range 0–1), respectively. All patients were able to resume work as well as sport activities. The postoperative complications included two coracoid process fractures, and none of the patients required additional surgery related to the index procedure.Conclusion All arthroscopic coracoclavicular button fixation of Neer type II distal clavicle fractures would provide sufficient stability and union with satisfactory radiological and clinical outcomes. This arthroscopic fixation technique would be more efficient than other osteosynthesis methods because it is a minimally invasive surgery with a low complication rate.Level of evidenceIII.
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BACKGROUND: Neer type II distal clavicle fractures have the drawback of coracoclavicular instability and insufficient distal bony fragment, thereby making it difficult to achieve adequate fixation. Although various surgical treatments have been described for Neer type II fracture, the optimal treatment remains controversial. This study reports the clinical results and usefulness of anatomical locking plate with additional K-wire fixation.METHODS: A totally of 21 patients with type II distal clavicle fracture were included in the study. The surgical procedure reduced the fracture temporarily; it included insertion of one or two K-wire from the lateral margin of the distal fragment to the proximal fragment through the fracture site, followed by application and fixation of the locking plate. The bony union and migration of K-wire was evaluated in the follow-up radiography. The coracoclavicular distance and acromioclavicular joint arthrosis were assessed at the final follow-up. The Constant Score (CS) and Korean Shoulder Score (KSS) were evaluated for clinical scoring.RESULTS: Bone union was achieved in all cases. At the final follow-up, coracoclavicular distance of the injured shoulder was increased, as compared to the intact shoulder (p=0.002), with no accompanying clinical symptoms. No K-wire migration was observed. At the final follow-up, K-wire irritation was observed in two cases and acromioclavicular arthrosis in one case, with no other adverse effects. Pain visual analogue scale, CS, and KSS were improved in all cases.CONCLUSIONS: The method of anatomical locking plate with additional K-wire fixation could be useful in achieving beneficial clinical results.
Article
Case: A 49-year-old man and a 37-year-old man with long oblique fractures of the distal clavicle were successfully treated with cerclage wiring fixation without detachment of the trapezius and deltoid muscles and exposure of the fracture site. Conclusions: Long oblique fractures with the acromioclavicular and coracoclavicular ligaments being intact and attached to the distal fragment are relatively rare among distal clavicle fractures. Cerclage wiring fixation is a viable treatment option for the fixation of long oblique fractures of the distal clavicle, with good clinical results and rapid recovery of shoulder function.
Article
Background: Osteosynthesis of distal clavicle fractures can be challenging because of comminution, poor bone quality, and deforming forces at the fracture site. A better understanding of regional differences in the bone structure of the distal clavicle is critical to refine fracture fixation strategies, but the variations in BMD and cortical thickness throughout the distal clavicle have not been previously described. Purpose: /questions (1) Which distal clavicular regions have the greatest BMD? (2) Which distal clavicular regions have the greatest cortical thickness values? Methods: Ten distal clavicle specimens were dissected from cadaveric shoulders. Eight specimens were female and two were male, with a mean (range) age of 63 years (59 to 67). The specimens were selected to match known epidemiology, as distal clavicular fractures occur more commonly in older patients with osteoporotic bone, and clavicular fractures in older patients are more common in females than males. The clavicles were then imaged using quantitative micro-CT to create 3-D images. The BMD and cortical thickness were calculated for 10 regions of interest in each specimen. These regions were selected to represent locations where distal clavicular fractures commonly occur and locations of likely bony comminution. Findings were compared between different regions using repeated measures ANOVA with Geiser-Greenhouse correction, followed by Bonferroni method multiple comparison testing. Effect size was also calculated to estimate the magnitude of difference between regions. Results: The four most medial regions of the distal clavicle contained the greatest BMD (anterior intertubercle space 887 ± 31 mgHA/cc, posterior intertubercle space 879 ± 26 mgHA/cc, anterior conoid tubercle 900 ± 21 mgHA/cc, posterior conoid tubercle 896 ± 27 mgHA/cc), while the four most lateral regions contained the least BMD (anterior lateral distal clavicle 804 ± 32 mgHA/cc, posterior lateral distal clavicle 800 ± 38 mgHA/cc, anterior medial distal clavicle 815 ± 27 mgHA/cc, posterior medial distal clavicle 795 ± 26 mgHA/cc). All four most medial regions had greater BMD than the four most lateral regions, with p < 0.001 for all comparisons. For the BMD ANOVA, η was determined to be 0.81, representing a large effect size. The four most medial regions of the distal clavicle also had the greatest cortical thickness (anterior intertubercle space 0.7 ± 0.2 mm, posterior intertubercle space 0.7 ± 0.3 mm, anterior conoid tubercle 0.9 ± 0.2 mm, posterior conoid tubercle 0.7 ± 0.2 mm), while the four most lateral regions had the smallest cortical thickness (anterior lateral distal clavicle 0.2 ± 0.1 mm, posterior lateral distal clavicle 0.2 ± 0.1 mm, anterior medial distal clavicle 0.3 ± 0.1 mm, posterior medial distal clavicle 0.2 ± 0.1 mm). All four most medial regions had greater cortical thickness than the four most lateral regions, with p < 0.001 for all comparisons. For the cortical thickness ANOVA, η was determined to be 0.80, representing a large effect size. No differences in BMDs and cortical thicknesses were found between anterior and posterior regions of interest in any given area. Conclusions: In the distal clavicle, BMD and cortical thickness are greatest in the conoid tubercle and intertubercle space. When compared with clavicular regions lateral to the trapezoid tubercle, the BMD and cortical thickness of the conoid tubercle and intertubercle space were increased, with a large magnitude of difference. Clinical relevance: Distal clavicular fractures are prone to comminution and modern treatment strategies have centered on the use of locking plate technology and/or suspensory fixation between the coracoid and the clavicle. However, screw pullout or cortical button pull through are known complications of locking plate and suspensory fixation, respectively. Therefore, it seems intuitive that implant placement during internal fixation of distal clavicle fractures should take advantage of the best-available bone. Although osteosynthesis was not directly studied, our study suggests that the best screw purchase in the distal clavicle is available in the areas of the conoid tubercle and intertubercle space, as these areas had the best bone quality. Targeting these areas during implant fixation would likely reduce implant failure and strengthen fixation. Future studies should build on our findings to determine if osteosynthesis of distal clavicular fractures with targeted screw purchase or cortical button placement in the conoid tubercle and intertubercle space increase fixation strength and decreases construct failure. Furthermore, our findings provide consideration for novel distal clavicular locking plate designs with modified screw trajectories or refined surgical techniques with suspensory fixation implants to reliably capture these areas of greatest bone quality.
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Osteoarthritic findings of the acromioclavicular joint are commonly observed in adult population, especially with increased age. For symptomatic patients who resulted in failed conservative treatment, surgical treatment is needed. In addition to the classic open procedure for distal clavicle resection, the arthroscopic procedure has recently been popularized. There have been some studies describing the advantages of the arthroscopic procedure including faster return to activities and less complication rate than the open procedure. There are two approaches in arthroscopic procedure: the lateral subacromial (indirect) approach and the superior (direct) approach. The latter approach has advantage to preserve the inferior AC ligament and coracoacromial arch during the surgery. The amount of resection has been discussed in anatomical studies regarding the AC ligament insertion. The dynamic examination during arthroscopy is helpful in determining the optimal amount of resection.
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Clavicle fractures are relatively common injuries that are typically diagnosed and followed with plain radiography. The goals of this article are to review the imaging evaluation, common classification systems, and relative surgical indications for clavicle fractures.
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The clavicular portion of the deltoid muscle (CPDM) in the human clavicle does not have a nomenclature in the Terminologia Anatomica (TA). This area is relevant in anatomy since the muscle participates in motions of glenohumeral articulation. The aim of this study was to describe the origin of the CPDM and to propose a name for the structure. Dry clavicles of 176 adults were studied, without distinction by sex. An osteometric board was used to measure the maximum length of the clavicles and a digital caliper to measure length of the CPDM's origin, distance from the origin to the sternal end, distance from the origin to the acromial end, distance of the lateral third and middle vertical diameter. The mean of maximum of the distances and CPDM's origin of left/right clavicle do not present significant differences. The CPDM s origin showed a high prevalence of structures as groove and roughened area (over 96% of cases). In conclusion, our definition of the CPDM shows the importance of clearly describing the observed groove and roughened area. Due to the high prevalence of the structures, the authors suggest that the terms "sulcus musculi deltoidei" and "tuberositas musculi deltoidei" be included in the TA to denominate the CPDM's origin on the human clavicle.
Article
Purpose: (1) Define the epidemiologic trend of distal clavicle excision (DCE) for acromioclavicular (AC) joint arthritis among board-eligible orthopaedic surgeons in the United States, (2) describe the rates and types of reported complications of open and arthroscopic DCE, and (3) evaluate the effect of fellowship training on preferred technique and reported complication rates. Methods: The American Board of Orthopaedic Surgery (ABOS) database was used to identify DCE cases submitted by ABOS Part II Board Certification examination candidates. Inclusion criteria were predetermined using a combination of ICD-9 and CPT codes. Cases were dichotomized into 2 groups: open or arthroscopic DCE. The 2 groups were then analyzed to determine trends in annual incidence, complication rates, and surgeon fellowship training. Results: From April 2004 to September 2013, there were 3,229 open and 12,782 arthroscopic DCE procedures performed and submitted by ABOS Part II Board Eligible candidates. Overall, the annual incidence of open DCE decreased (78-37 cases per 10,000 submitted cases, P = .023). Although the annual number of arthroscopic DCE remained steady (1160-1125, P = .622), the percentage of DCE cases performed arthroscopically increased (65%-79%, P = .033). Surgeons without fellowship training were most likely to perform a DCE via an open approach (31%) whereas surgeons with sports medicine training were more likely to perform DCE arthroscopically compared with other fellowship groups (88%, P < .001). Open DCE was associated with a higher surgical complication rate overall when compared with arthroscopic DCE (9.4% vs 7.6%, respectively; P < .001). When compared with other fellowship-trained surgeons, sports medicine surgeons maintained a lower reported surgical complication rate whether performing open or arthroscopic DCE (5.5%, P = .027). Conclusions: In recent years, open management of AC joint arthritis has declined among newly trained, board-eligible orthopaedic surgeons, possibly because of an increased complication rate associated with open treatment. Fellowship training was significantly associated with the type of treatment (open vs arthroscopic) rendered and complication rates. Level of evidence: Level IV, case series.
Article
Fractures of the distal clavicle represent 15–30% of all clavicle fractures. The local osseoligamentous anatomy and deforming forces result in increased risk of delayed union and nonunion than fractures in other parts of the clavicle. These factors also contribute to challenges in fracture repair. Understanding these injuries and their imaging features enhances care and ensures patients are directed to appropriate management. We review the anatomy of the distal clavicle and surrounding ligaments, options for radiographic evaluation, relevant classification systems, and current concepts in management. Illustrative examples of specialized views are provided. Pediatric acromioclavicular joint pseudosubluxation is also reviewed, with findings specific to that injury.
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This chapter reviews the relevant anatomy of the acromioclavicular joint as well as the epidemiology, mechanism of injury, physical exam findings, pertinent imaging, classification and nonoperative treatment guidelines for injuries of this articulation.
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Fractures of the medial clavicle are rare comprising 2–4% of all clavicle fractures while those of the distal clavicle account for approximately 10–30%. Medial fractures are less likely to be displaced compared to those of the diaphysis, seldom involve the sternoclavicular joint, and most often are treated nonoperatively. The majority of distal clavicle fractures are minimally displaced, extra-articular, and typically managed nonoperatively. Operative treatment for medial clavicle fractures is reserved for select clinical scenarios given the proximity of critical anatomic structures. This includes open fractures, fractures with neurovascular compromise threatening mediastinal contents, and highly unstable bipolar clavicle fractures. A particular subset of distal clavicle injuries is inherently unstable, prone to displacement, and is at risk for delayed or nonunion. Distinguishing the subtle variations in distal clavicle fracture stability can be challenging and ultimately guides treatment decisions. However, nonunions are often asymptomatic, and the preferred operative fixation remains controversial.
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Clavicle fractures are common in the pediatric and adolescent populations. This chapter examines the epidemiology, pathoanatomy, assessment, diagnosis, and treatment options of midshaft and distal clavicle fractures. Despite the high incidence of these injuries, outcomes in children have not been extensively studied. Data from the limited number of pediatric studies as well as data extrapolated from the adult literature will be discussed. The nonoperative and operative management options are presented from technique to outcome, along with their associated complications.
Article
Acromioclavicular (AC) joint injury is encountered commonly in the general population, accounting for up to 9% of all shoulder injuries, but it can be seen with a significantly higher prevalence in athletes. In particular, the thrower's shoulder experiences significant rotational forces at the AC joint, meriting special focus when formulating treatment of AC joint pathology to preserve effective overhead mechanics. AC joint pathology observed frequently in an athletic population includes traumatic AC joint instability, distal clavicular fracture, and distal clavicular osteolysis. Appropriate treatment requires knowledge of AC joint anatomy and biomechanics, relevant pathophysiology, and both operative and nonoperative options.
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The diagnosis, prognosis and management of acromioclavicular joint instability remain a point of debate with over 60 types of stabilization procedure described in the published literature. This is a sure sign that we are yet to solve the problem of AC joint instability. In this chapter, we describe the pathoanatomy of AC joint instability using historical articles and classification systems and use these to outline a progressive concept of AC joint instability that will further the reader’s understanding of the problem and how to solve it.
Chapter
The coracoid process comes off the scapula at the upper base of the neck of the glenoid and passes anteriorly before hooking to a more lateral position. Ejnisman et al. showed in cadaveric study that the average length of the coracoid process is approximately 4.3 cm. The width and height at the tip is 2.1 and 1.5 cm, respectively. It functions as the origin of the short head of the biceps and the coracobrachialis tendons. It also serves as the insertion of the pectoralis minor muscle and the coracoacromial, coracohumeral, and coracoclavicular ligaments . The coracoid process is not easily visualized on a radiograph. Apart from the usual three-view trauma series, an AP tilt view (35–60°) and a Stryker notch view. A CT scan with three-dimensional reconstruction images will give more insight into the fracture pattern. The coracoid can impinge on the head of the humerus and subscapularis tendon and is thought to be an important factor in the development of degeneration and tears of the subscapularis tendon. The coracoid process can be the site of primary or metastatic (breast or lung) tumors.
Article
Introduction: Resection of the distal aspect of clavicle has a well-documented treatment modality in case of acromioclavicular joint osteoarthritis resistant to conservative treatment. Hypothesis: Limited (mean ∼0.5cm distal end of clavicle resection) distal clavicle excision of A-C joint arthritis in cases resistant to conservative treatment may reduce the pain and improve the shoulder function. Material and methods: In this study, we retrospectively evaluated the results of limited distal clavicle excision of acromioclavicular joint osteoarthritis resistant to conservative treatment. All patients were evaluated by using the Visual Analogue Scale (VAS) and UCLA shoulder rating scale (University of California Los Angeles), either before surgery or final follow-up period for pain and functional results, respectively. Results: A total of 110 patients (48 male, 62 female) with AC joint arthritis, treated between the years of 2008-2012, were retrospectively analyzed. A total of 30 patients (12 male, 18 female) who failed to show improvement with conservative treatment underwent limited surgical open excision of distal clavicle. The mean age of the study population was 52.5±1.2 years. The mean follow-up period was 27±1.3 months. The mean preoperative VAS score was 83.6±5.58 (range, 70-90) while mean VAS was 26.6±9.3 (range, 10-50) at the final follow-up. There was a statistically significant difference between pre- and postoperative VAS scores in patients who had treated by surgical approach (P<0.001). The mean UCLA score of the patients increased postoperatively from 11.5 (range, 9-14) to 29.2 (range, 27-32) at the final follow-up. There was a statistically significant difference between the two time periods with respect to UCLA scores (P<0.001). Discussion and conclusion: In patients with AC osteoarthritis resistant to conservative therapy, the hypothesized limited clavicle excision (mean ∼0.5cm distal end of clavicle resection with preserving coracoclavicular ligaments and inferior capsule) reduced the pain and improved the shoulder function. Conclusion: Our midterm follow-up (mean 27 months) results showed that limited distal clavicle excision of patients with AC joint osteoarthritis resistant to conservative treatment (0.5cm distal end of clavicle resection with preserving inferior capsule, and coracoclavicular ligaments) reduced the pain and improved the shoulder function. Level of evidence: IV (Retrospective study).
Chapter
The shoulder girdle is a common vernacular for referencing a complex musculoskeletal arrangement which allows for coordinated function of the humerus, clavicle, scapula, and thorax. Shoulder girdle injuries cross a large spectrum ranging from sterno- and acromioclavicular disruptions, to complex fractures, to muscular tears. In the context of chest wall injuries, particularly multi-segment rib fractures occurring in high-energy mechanisms, ipsilateral injuries to the shoulder girdle are common. This chapter will describe the diagnosis, treatment, and outcome of associated injuries to the clavicle and scapula.
Chapter
Clavicle fractures are common in the pediatric and adolescent populations. This chapter examines the epidemiology, pathoanatomy, assessment, diagnosis, and treatment options of midshaft and distal clavicle fractures. Despite the high incidence of these injuries, outcomes in children have not been extensively studied. Data from the limited number of pediatric studies as well as data extrapolated from the adult literature will be discussed. The nonoperative and operative management options are presented from technique to outcome, along with their associated complications.
Article
Background: The failure of subacromial decompression may be attributed to persistent symptoms of acromioclavicular joint (ACJ) arthritis, while inferior clavicular spurs of the ACJ may be associated with failed healing of repaired rotator cuffs. Purpose: To evaluate the clinical effectiveness of arthroscopic distal clavicle resection (DCR) in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis. Study design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 78 patients with rotator cuff tears in addition to radiological and asymptomatic ACJ arthritis who were scheduled for arthroscopic rotator cuff repair were prospectively randomized into 2 groups. Patients underwent arthroscopic rotator cuff repair with acromioplasty. Patients in group 1 (39 patients) underwent additional arthroscopic DCR, while patients in group 2 (39 patients) did not. Clinical outcomes of the 2 groups were compared using the visual analog scale (VAS) for pain, range of motion, Constant score, and American Shoulder and Elbow Surgeons (ASES) score up to at least 24 months. The structural integrity of repaired rotator cuffs was assessed using ultrasonography, computed tomography arthrography, or MRI at least 6 months after surgery. To evaluate ACJ instability, weighted stress radiography of the ACJ was studied at 6 and 12 months postoperatively. Results: Patients in both groups showed significant improvement in the VAS score and all functional scores at final follow-up (mean, 29.2 months; range, 24-46 months) without significant differences between the 2 groups (P > .05). Results (mean ± SD) for preoperative group 1/group 2 and postoperative group 1/group 2 were as follows, respectively: 7.2 ± 1.8/6.1 ± 1.9 (P = .02) and 0.6 ± 1.8/0.6 ± 0.9 (P = .97) for the VAS score, 74.1 ± 5.7/73.8 ± 8.0 (P = .87) and 96.3 ± 5.7/95.7 ± 4.6 (P = .77) for the Constant score, and 47.0 ± 10.3/50.8 ± 14.1 (P = .22) and 91.5 ± 15.5/94.5 ± 11.8 (P = .55) for the ASES score. Failed cuff healing occurred in 9 patients (23%) in group 1 and 10 patients (26%) in group 2, with no significant difference (P = .95). In group 1, there were 2 patients (5.0%) with ACJ subluxation on weighted stress radiography at 6 months postoperatively. These patients complained of gross protrusion and ACJ tenderness. Conclusion: Preventive arthroscopic DCR in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis did not result in better clinical or structural outcomes, and it did lead to symptomatic ACJ instability in some patients. Preventive arthroscopic DCR is not recommended in patients with radiological but asymptomatic ACJ arthritis. Further long-term follow-up is needed to confirm the development of symptoms in ACJ arthritis.
Article
Resection of the lateral end of the clavicle disrupts the acromioclavicular articulation and creates the potential for abnormal postoperative motion. Seventeen isolated distal clavicle resections were reviewed to assess translation of the acromioclavicular articulation in the anteroposterior plane and its relationship to patient outcome. Stress radiographs were used to quantitate the translation of the distal clavicle and the amount of bone resected. Radiographs of the contralateral shoulder served as a control. Patients completed a questionnaire on shoulder function and pain and were examined preoperatively and postoperatively. The total translation (anterior plus posterior) in the anteroposterior plane averaged 8.7 mm (range, 3-21 mm) for surgically treated shoulders and was significantly greater than that for the contralateral shoulders (mean, 3.2 mm; range, 1-6 mm). Patients' postoperative visual analog pain scales correlated with the magnitude of anteroposterior translation. The amount of translation and the postoperative pain scores did not correlate with the apparent joint space seen on radiographs after surgery. The correlation of pain scores with the amount of translation shows that excessive anteroposterior instability of the distal clavicle can cause postoperative shoulder pain and poor surgical outcome.
Article
Distal clavicle resection has been an effective procedure for treatment of acromioclavicular arthritis. The conven tional open surgical technique involves deltoid detach ment and reattachment, which may cause postopera tive weakness and requires protection during the post operative period to allow for healing. Arthroscopic acromioclavicular joint resection has the theoretical ad vantages of no deltoid disruption and a shorter rehabil itation period. The purpose of this study was to com pare open versus arthroscopic acromioclavicular joint resection in a laboratory setting. The goals of acromioclavicular joint resection in this study were to remove 5 mm of the medial acromion and 10 mm of the distal clavicle. Acromioclavicular joint resections were performed on 10 cadaver shoulders (5 open resections and 5 arthroscopic resections). Open resection was successful at 10 of 15 distal clavicle locations and 14 of 15 medial acromial locations. Ar throscopic resection was successful at 14 of 15 distal clavicle locations and 10 of 15 medial acromial loca tions. The combined bone resection averaged 14.8 mm (±1.99 mm) for the open technique and 14.8 mm (± 2.58 mm) for the arthroscopic technique. The combined bone resection was 1.5 cm or more in all of the meas ured locations for the open technique and in 14 of 15 measure locations for the arthroscopic technique. There was no statistically significant difference between the two groups. In the laboratory setting, acromioclavicular joint re section was performed effectively and predictably with arthroscopic instruments. Arthroscopic bone resection was comparable to open bone resection.
Article
Histologic sections of dog mandibles and teeth were stained with picrosirius red and Mayer's hematoxylin. Collagenous structures of the mandible stained brilliant red. Dentinal tubules, Sharpey's fibers and other structures not easily seen in sections stained with hematoxylin and eosin alone were seen clearly after this procedure. Under polarized light collagen fibers could be specifically identified and their orientation determined. Picrosirius red-hematoxylin is recommended for examination of normal or pathologic dental specimens.
Article
An anatomical study of the acromioclavicular (AC) joint and its supporting ligaments was performed using both macroscopic and microscopic methods. The project used 63 cadaver shoulders of unknown ages. Fifty-three joints were used for macroscopic and 10 for microscopic study. The data consisted of micrometer measurements of the dimensions of the extrinsic and intrinsic ligaments of the AC joint; measurement and description of the intraarticular meniscus and the superior and inferior capsular ligaments of the AC joint; and the anatomical course and relationship of the coracoacromial (CA) ligament to the supporting ligaments of the AC joint and a description of its insertion on the acromion process. The following observations were made: The coracoclavicular ligament, especially the trapezoid ligament, provides significant soft tissue restraints to upward displacement of the clavicle. A complete AC joint disc was found in only one, meniscoid discs in 25, remnants of discs in 16, and no discs in 11 of the 53 joints studied macroscopically. (No age correlation was made since the ages of the cadavers were unknown). The CA ligament interconnects with the inferior capsular ligament of the AC joint as well as with the coracoclavicular and coracohumeral ligaments. It also has a broad area of insertion on the inferior acromial surface. The CA ligament appears to function as a buffer between the acromion and the rotator cuff, and to provide support for the AC joint. Transection of the CA ligament may result in loss of this buffering function.
Article
The ligamentous structures of the acromioclavicular joint were studied by gross examination and quantitative measurement in twelve human cadaver specimens. Distances between insertions at various extreme positions of the clavicle were studied with the biplane radiographic technique. Ligamentous contributions to joint constraint under displacements were determined by performing load-displacement tests along with sequential sectioning of the ligaments. Twelve modes of joint displacement were examined. The acromioclavicular ligament acted as a primary constraint for posterior displacement of the clavicle and posterior axial rotation. The conoid ligament appeared to be more important than has been previously described. That ligament played a primary role in constraining anterior and superior rotation as well as anterior and superior displacement of the clavicle. The trapezoid ligament contributed less constraint to movement of the clavicle in both the horizontal and the vertical plane except when the clavicle moved in axial compression toward the acromion process. The various contributions of different ligaments to constraint changed not only with the direction of joint displacement but also with the amount of loading and displacement. For many directions of displacement, the acromioclavicular joint contributed a greater amount to constraint at smaller degrees of displacement, while the coracoclavicular ligaments, primarily the conoid ligament, contributed a greater amount of constraint with larger amounts of displacement.
Article
Impingement lesions are considered in three progressive stages: I, edema and hemorrhage; II, fibrosis and tendinitis; III, tears of the rotator cuff, biceps ruptures, and bone changes. The physical findings in all of these stages are similar, accounting for some of the misconceptions about tears of the rotator cuff. The 'impingement test' identifies these lesions. Arthrography is the most reliable method of identifying complete-thickness tears from other impingement lesions. Further observations confirm that impingement occurs anteriorly, not laterally. It is thought that most supraspinatus and biceps lesions are due to impingement wear, usually caused in part by variations in the shape and slope of the acromion. When these tendons rupture, impingement may be escalated, because the head is allowed to migrate upward. Anterior acromioplasty is used routinely when tears of the rotator cuff are repaired, to decompress the supraspinatus from continuing wear. It is also used for chronic disability associated with incomplete tears but only occasionally in patients younger than 40 years of age. The approach offered by an anterior acromioplasty for repairing the rotator cuff offers three advantages over lateral acromionectomy: (1) less deltoid detachment; (2) better exposure of the supraspinatus; and (3) better decompression of the supraspinatus against continuing impingement. Small, unfused anterior acromial epiphyses are excised, whereas larger, unfused centers are tilted up and closed by curettage and local bone grafts, and internally fixed with screws or threaded wires.
Article
Since 1941, distal clavicle excision has been a reliable technique for alleviating pain caused by acromioclavicular joint arthritis. Disadvantages of the procedure include permanent shoulder weakness, a lengthy recovery time ranging from weeks to months before useful function of the extremity returns, and lack of cosmesis. By modifying the standard portals used to perform arthroscopic subacromial decompression, the authors have successfully excised the distal clavicle of ten consecutive patients. Using this arthroscopic technique, the surgical time averaged approximately one hour 40 minutes, blood loss was negligible, and there were no complications. Operations were performed in an outpatient setting. Five of ten patients missed work only on the day of surgery, and seven of ten patients required no formal physical therapy. All ten patients achieved a good or excellent result on the UCLA. Shoulder Scale for short-term follow-up evaluation. Postoperative radiographs documented adequate bone resection in all cases. In experienced hands, arthroscopic distal clavicle excision is an excellent substitute for the "open" procedure.
Article
This article describes a new technique and instrumentation for performing arthroscopic distal clavicle resection safely and accurately using the three standard portals for shoulder arthroscopy. A simple six-step surgical technique is reviewed. Clinical results of patients who have undergone an arthroscopic Mumford procedure using this technique are presented also.
Article
Painful conditions of the acromioclavicular joint without instability can be treated successfully with arthroscopic methods. The direct approach is best suited for isolated acromioclavicular pathology. It also can be used to address the acromioclavicular joint during shoulder arthroscopy and bursoscopy, but two additional acromioclavicular portals are needed. In patients with both subacromial and acromioclavicular joint pathology, the bursal approach to the acromioclavicular joint can be used. In some patients with narrow or medially inclined overriding clavicles, the distal clavicle is not easily resected with the bursal approach. The direct approach is an alternative in these situations. Either method has been shown to be an effective treatment and can return the patient to full activity much sooner than with a traditional open resection.
Article
Seventy-three patients had operative resection of the lateral end of the clavicle for the treatment of a painful condition of the acromioclavicular joint. Thirty-two of the patients had had a traumatic separation of the acromioclavicular joint, eight had had a fracture of the lateral end of the clavicle, and thirty-three had primary acromioclavicular osteoarthrosis. An average of sixteen millimeters (range, five to thirty-seven millimeters) was resected; the amount was similar in each of the three groups. The patients were evaluated an average of nine years (range, four to sixteen years) after the operation. The result was considered good in twenty-one patients, satisfactory in twenty-nine, and poor in twenty-three. A poor result was more common in the patients who had had a fracture of the lateral end of the clavicle (p < 0.01). Forty-six patients reported pain with exertion, and thirteen noted pain at rest. Eighteen patients had a decrease in the strength of the involved upper extremity, and sixteen had some limitation of the mobility of the shoulder. Elevation of the lateral end of the remaining part of the clavicle as compared with the scapula was noted in eighteen patients and was more likely to be associated with pain (p < 0.05). The extent of the resection was significantly associated with pain; patients who had had a smaller amount of resection (ten millimeters or less) had less pain than those who had had a larger amount (p < 0.03). A good result was more common in the patients in whom less than ten millimeters had been resected and who had had a previous traumatic separation of the acromioclavicular joint or had primary acromioclavicular osteoarthrosis. We recommend that resection of the lateral end of the clavicle be considered with caution for patients who have severe post-traumatic or degenerative osteoarthrosis of the acromioclavicular joint. If resection is performed, it should not exceed ten millimeters.
Article
To determine the role of the acromioclavicular ligaments in controlling scapular rotation about the distal clavicle and the effects of distal clavicle resection, we used 13 fresh shoulders consisting of the clavicle, acromioclavicular ligaments, coracoclavicular ligaments, and scapula. The range of motion was measured using a specially designed goniometer for each of the three orthogonal axes of rotation of the scapula with reference to the clavicle: anterior-posterior axial rotation, protraction-retraction, and abduction-adduction. We did two experiments involving sequential sectioning. Range of motion was measured in the intact shoulder and after each sectioning cut. The order of sectioning in Experiment 1 (six shoulders) was 1) the inferior acromioclavicular ligament, 2) removal of 5 mm of the distal clavicle, and 3) the superior acromioclavicular ligament. In Experiment 2 (seven shoulders) the order was 1) the superior acromioclavicular ligament, 2) removal of 5 mm of the distal clavicle, and 3) the inferior acromioclavicular ligament. The most important results were 1) only 5 mm of the distal clavicle needs to be resected to ensure that no bone-to-bone contact occurs in rotation postoperatively and 2) there was no difference in the end result (for range of motion in any of the three axes) whether the inferior acromioclavicular ligament or the superior acromioclavicular ligament was cut before removal of 5 mm of the distal clavicle.
Trends in treatment of complete acromioclavicular dislocations
  • Rowe
Anatomical observations on the acromioclavicular joint and supporting ligaments
  • Salter