Medial placement of trapezoid tunnel leads to higher reduction loss in acute acromioclavicular joint dislocation treated with anatomic coracoclavicular fixation.

Aim: To analyze the association between clavicular tunnel positioning and postoperative reduction loss in patients with acute acromioclavicular (AC) joint dislocation treated with anatomic coracoclavicular (CC) fixation using double clavicular tunnels. Methods: A retrospective review of patients with AC joint dislocation, treated with anatomic CC fixation using double clavicular tunnels, was conducted. Patients with pre-operative, immediate post-operative, and final follow-up Zanca-view X-rays were included. On each X-ray, the obtained measures included: distance from lateral border of clavicle to trapezoid and conoid tunnels, distance between tunnels, clavicle length, and CC distance of affected and un-affected sides. Loss of reduction was calculated as CC distance difference between immediate and final post-operative X-rays. Association between reduction loss and tunnel positioning was analyzed. Results: Conoid, trapezoid and tunnel ratios were 24% ± 4, 15% ± 3, and 9% ± 2, respectively. Significant reduction loss was seen in 21(45.7%) patients. Significantly higher probabilities of reduction loss were associated with trapezoid tunnels placed medial to 24 mm (30.8% vs 65.0%, OR 4.2 (IC95%: 1.2-14.4), p: 0.024) or 15% of the clavicle length (32.1% vs 66.7%, OR 4.2 (IC 95%: 1.2-14.9), p: 0.025). Conclusions: Trapezoid tunnels placed medial to 24 mm or 15% medial to clavicle length could lead to higher probabilities of significant reduction loss. These findings support the importance of clavicular tunnels' proper placement for decreasing significant reduction loss.

No existe diferencia en desenlaces clínicos en pacientes con fracturas de clavícula distal Neer II y Neer V tratados con o sin sistemas de aumentación coracoclavicular / There is no difference in clinical outcomes in patients with distal Neer II and Neer V clavicle fractures treated with or without coracoclavicular augmentation systems

Resumen: Introducción: el uso de sistemas de aumentación coracoclaviculares en combinación con placas bloqueadas en el tratamiento de las fracturas de clavícula distal inestables es controvertido. Material y métodos: se han revisado retrospectivamente los pacientes con fracturas distales de clavícula inestables tratados entre 2013-2022 en Hospital Clínic de Barcelona. Se dividieron a los pacientes en dos grupos: pacientes tratados con placas bloqueadas (grupo P) y pacientes tratados con placas bloqueadas y sistemas de aumentación coracoclaviculares (grupo PCC). Se registraron las complicaciones postoperatorias, distancia CC (coracoclavicular) modificada preoperatoria y final, así como los resultados en la escala visual analógica (EVA) y en el Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH). Resultados: de un total de 23 pacientes, 16 se trataron sólo con placas y siete con placas y sistemas de aumentación coracoclaviculares. Se observó ausencia de consolidación en un caso e infección cutánea en otro. La distancia CC final media fue de 23.7 mm en el grupo P y de 22.1 mm en el grupo PCC. La media de la EVA fue de 1.3 en ambos grupos, mientras que el Quick DASH tuvo media de 5.5 en el grupo P y de 8.1 en el grupo PCC. No se encontraron diferencias significativas en la distancia CC, en la EVA ni en el Quick DASH. Conclusión: los resultados sugieren que el uso de placas bloqueadas es probablemente suficiente en el manejo de las fracturas de clavícula distales inestables, sin observar diferencias significativas en los resultados funcionales al agregar sistemas de aumentación coracoclavicular.

Abstract: Introduction: the use of coracoclavicular augmentation systems together with locking plates in the treatment of unstable distal clavicle fractures (Neer II and Neer V) is controversial. Material and methods: patients with unstable distal clavicle fractures treated between 2013-2022 were retrospectively reviewed. The patients were divided into two groups: patients treated with locking plates (P group) and patients treated with locking plates and coracoclavicular augmentation systems (PCC group). Postoperative complications, modified preoperative and final coracoclavicular distance (CC), and outcomes on the Visual Analog Scale (VAS) and Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) were recorded. Results: 16 of 23 patients were treated with plates only, and 7 of 23 were treated with plates and coracoclavicular augmentation systems. One case showed no fracture consolidation, and there was one case of cutaneous infection. The mean final CC distance was 23.7 in the P group and 22.1 in the PCC group. The mean VAS score was 1.3 in both the P and PCC groups, while the mean Quick DASH score was 5.5 in the P group and 8.1 in the PCC group. No significant differences were found in CC distance, VAS or Quick DASH scores. Conclusion: the use of locking plates is likely sufficient in the management of unstable distal clavicle fractures, as there were no significant differences in functional outcomes in this study when coracoclavicular augmentation systems were used together with locking plates.

Anatomic coracoclavicular ligament reconstruction with triple flip-buttons leads to good functional outcomes and low reduction loss: a case series.

BACKGROUND: The management of acromioclavicular (AC) joint dislocation remains controversial. Recently, anatomic coracoclavicular (CC) fixation with a double clavicular tunnel and three flip-buttons has shown promising results. This study aimed to evaluate functional and radiological outcomes in patients with high-grade AC joint dislocation treated with anatomic CC fixation using double clavicular tunnels and three flip-buttons. METHODS: A retrospective, unicentric study was performed. The study included patients with high-grade AC joint dislocation who underwent surgery with anatomic CC fixation using double clavicular tunnels and three flip-buttons. Demographic data were obtained from medical records. A functional evaluation using subjective shoulder value (SSV), visual analog scale (VAS), and disabilities of the arm, shoulder, and hand (DASH) questionnaires was performed, and an evaluation of preoperative and postoperative comparative Zanca view images was performed. Factors associated with functional outcomes and radiological AC reduction were analyzed. RESULTS: A total of 83 patients completed follow-up and were included in the analysis. The mean SSV, VAS, and DASH scores were 92.8, 0.8, and 6.4, respectively. Patients who had complications experienced significantly worse functional outcomes (DASH: P=0.037). Suboptimal final AC reduction was observed in nine patients (11.1%), and significantly more frequently in patients older than 40 years (P=0.031) and in surgeries performed more than 7 days after injury (P=0.034). There were two reoperations (2.4%). CONCLUSIONS: Anatomic CC fixation with a double clavicular tunnel and three flip-buttons leads to good functional outcomes, low complication rates, and high rates of optimal AC reduction. Level of Evidence: Level IV; Case series.

[There is no difference in clinical outcomes in patients with distal Neer II and Neer V clavicle fractures treated with or without coracoclavicular augmentation systems]. / No existe diferencia en desenlaces clínicos en pacientes con fracturas de clavícula distal Neer II y Neer V tratados con o sin sistemas de aumentación coracoclavicular.

INTRODUCTION: the use of coracoclavicular augmentation systems together with locking plates in the treatment of unstable distal clavicle fractures (Neer II and Neer V) is controversial. MATERIAL AND METHODS: patients with unstable distal clavicle fractures treated between 2013-2022 were retrospectively reviewed. The patients were divided into two groups: patients treated with locking plates (P group) and patients treated with locking plates and coracoclavicular augmentation systems (PCC group). Postoperative complications, modified preoperative and final coracoclavicular distance (CC), and outcomes on the Visual Analog Scale (VAS) and Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) were recorded. RESULTS: 16 of 23 patients were treated with plates only, and 7 of 23 were treated with plates and coracoclavicular augmentation systems. One case showed no fracture consolidation, and there was one case of cutaneous infection. The mean final CC distance was 23.7 in the P group and 22.1 in the PCC group. The mean VAS score was 1.3 in both the P and PCC groups, while the mean Quick DASH score was 5.5 in the P group and 8.1 in the PCC group. No significant differences were found in CC distance, VAS or Quick DASH scores. CONCLUSION: the use of locking plates is likely sufficient in the management of unstable distal clavicle fractures, as there were no significant differences in functional outcomes in this study when coracoclavicular augmentation systems were used together with locking plates.

INTRODUCCIÓN: el uso de sistemas de aumentación coracoclaviculares en combinación con placas bloqueadas en el tratamiento de las fracturas de clavícula distal inestables es controvertido. MATERIAL Y MÉTODOS: se han revisado retrospectivamente los pacientes con fracturas distales de clavícula inestables tratados entre 2013-2022 en Hospital Clínic de Barcelona. Se dividieron a los pacientes en dos grupos: pacientes tratados con placas bloqueadas (grupo P) y pacientes tratados con placas bloqueadas y sistemas de aumentación coracoclaviculares (grupo PCC). Se registraron las complicaciones postoperatorias, distancia CC (coracoclavicular) modificada preoperatoria y final, así como los resultados en la escala visual analógica (EVA) y en el Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH). RESULTADOS: de un total de 23 pacientes, 16 se trataron sólo con placas y siete con placas y sistemas de aumentación coracoclaviculares. Se observó ausencia de consolidación en un caso e infección cutánea en otro. La distancia CC final media fue de 23.7 mm en el grupo P y de 22.1 mm en el grupo PCC. La media de la EVA fue de 1.3 en ambos grupos, mientras que el Quick DASH tuvo media de 5.5 en el grupo P y de 8.1 en el grupo PCC. No se encontraron diferencias significativas en la distancia CC, en la EVA ni en el Quick DASH. CONCLUSIÓN: los resultados sugieren que el uso de placas bloqueadas es probablemente suficiente en el manejo de las fracturas de clavícula distales inestables, sin observar diferencias significativas en los resultados funcionales al agregar sistemas de aumentación coracoclavicular.

[Restoring horizontal stability in III-V acromioclavicular dislocations by anatomic reconstruction of the coracoclavicular and acromioclavicular ligaments; surgical technique]. / Restablecimiento de la estabilidad horizontal en luxaciones acromioclaviculares III-V mediante la reconstrucción anatómica de los ligamentos coracoclaviculares y acromioclaviculares; técnica quirúrgica.

INTRODUCTION: dislocation of the acromioclavicular (AC) joint is a common injury seen in young adults. The objective is to describe a surgical technique that can restore the horizontal and vertical stability of the AC joint. MATERIAL AND METHODS: we describe a surgical technique that can restore horizontal and vertical stability using an allograft for the anatomical reconstruction of the CC and AC ligaments, for AC grade III-V dislocations according to the Rockwood classification. RESULTS: this is a surgical technique with anatomical and biological reconstruction of the CC and AC ligaments, using an allograft. Two bone tunnels are made in the clavicle, passing the lateral end of the graft below the acromion; then the two ends are fixed with two bioabsorbable screws, restoring vertical and horizontal stability. CONCLUSION: this procedure allows to restore the vertical and horizontal stability of the AC joint. Follow up studies are required to report functional and radiological results, in order to ensure advantages compared to existing techniques.

INTRODUCCIÓN: la luxación de la articulación acromioclavicular (AC) es una lesión frecuente que se observa en adultos jóvenes. El objetivo es describir una técnica quirúrgica que pueda restablecer la estabilidad horizontal y vertical de la articulación AC. MATERIAL Y MÉTODOS: se describe una técnica quirúrgica utilizando un aloinjerto para la reconstrucción anatómica de los ligamentos coracoclaviculares (CC) y AC para luxaciones AC grado III-V de acuerdo con la clasificación de Rockwood. RESULTADOS: es una técnica quirúrgica con reconstrucción anatómica y biológica de los ligamentos CC y AC con injerto. Se realizan dos túneles óseos en la clavícula pasando el cabo lateral del injerto por debajo del acromion; posteriormente se fijan los dos cabos con dos tornillos bioabsorbibles, restaurando de esta manera la estabilidad vertical y horizontal. CONCLUSIÓN: este procedimiento permite restablecer la estabilidad vertical y horizontal de la articulación AC. Se requieren estudios de seguimiento para reportar resultados funcionales y radiológicos con el fin de poder asegurar ventajas en comparación con las técnicas existentes.

Restablecimiento de la estabilidad horizontal en luxaciones acromioclaviculares III-V mediante la reconstrucción anatómica de los ligamentos coracoclaviculares y acromioclaviculares; técnica quirúrgica / Restoring horizontal stability in III-V acromioclavicular dislocations by anatomic reconstruction of the coracoclavicular and acromioclavicular ligaments; surgical technique

Resumen: Introducción: la luxación de la articulación acromioclavicular (AC) es una lesión frecuente que se observa en adultos jóvenes. El objetivo es describir una técnica quirúrgica que pueda restablecer la estabilidad horizontal y vertical de la articulación AC. Material y métodos: se describe una técnica quirúrgica utilizando un aloinjerto para la reconstrucción anatómica de los ligamentos coracoclaviculares (CC) y AC para luxaciones AC grado III-V de acuerdo con la clasificación de Rockwood. Resultados: es una técnica quirúrgica con reconstrucción anatómica y biológica de los ligamentos CC y AC con injerto. Se realizan dos túneles óseos en la clavícula pasando el cabo lateral del injerto por debajo del acromion; posteriormente se fijan los dos cabos con dos tornillos bioabsorbibles, restaurando de esta manera la estabilidad vertical y horizontal. Conclusión: este procedimiento permite restablecer la estabilidad vertical y horizontal de la articulación AC. Se requieren estudios de seguimiento para reportar resultados funcionales y radiológicos con el fin de poder asegurar ventajas en comparación con las técnicas existentes.

Abstract: Introduction: dislocation of the acromioclavicular (AC) joint is a common injury seen in young adults. The objective is to describe a surgical technique that can restore the horizontal and vertical stability of the AC joint. Material and methods: we describe a surgical technique that can restore horizontal and vertical stability using an allograft for the anatomical reconstruction of the CC and AC ligaments, for AC grade III-V dislocations according to the Rockwood classification. Results: this is a surgical technique with anatomical and biological reconstruction of the CC and AC ligaments, using an allograft. Two bone tunnels are made in the clavicle, passing the lateral end of the graft below the acromion; then the two ends are fixed with two bioabsorbable screws, restoring vertical and horizontal stability. Conclusion: this procedure allows to restore the vertical and horizontal stability of the AC joint. Follow up studies are required to report functional and radiological results, in order to ensure advantages compared to existing techniques.

[Coraco-clavicular loop and tension band suture in type II and type V distal-third clavicle fractures]. / Cerclaje coracoclavicular y banda de tensión con sutura en el tratamiento de fracturas del tercio externo de la clavícula tipos II y V.

Many surgical techniques have been used to address unstable distal third clavicle fractures. Complications and the need for hardware removal are still a concern. We propose a surgical technical using high-strength sutures to restore vertical and horizontal stability in Neer type II and Neer type V distal-third clavicle fractures. It has been used in three cases; two type V and one type II. In all cases, bone healing was achieved uneventfully and all patients resumed their pre-injury activities including sports at sixmonths postoperatively. The coraco-clavicular loop and tension band suture technique is a simple procedure that allows vertical and horizontal stabilization of the fracture. It achieves good clinical results and it may be a costeffective alternative to other techniques although a longer series and longterm followup is required to adequately assess the results.

Se han descrito diferentes técnicas quirúrgicas para el tratamiento de las fracturas inestables del tercio distal de la clavícula. Las complicaciones asociadas y la necesidad de retirar los implantes siguen siendo motivo de preocupación. Proponemos una técnica quirúrgica que utiliza suturas de alta resistencia para restaurar la estabilidad vertical y horizontal en las fracturas del tercio distal de la clavícula de tipo II y V de la clasificación de Neer. Esta técnica se ha utilizado en tres casos; dos de tipo V y uno de tipo II. En todos se obtuvo la consolidación ósea y todos reanudaron sus actividades previas a la lesión, incluyendo actividad deportiva, a los seis meses de la cirugía. La técnica de cerclaje coracoclavicular y banda de tensión con sutura es un procedimiento sencillo que permite la estabilización vertical y horizontal de la fractura. Permite obtener buenos resultados clínicos y puede ser una alternativa coste-efectiva eficaz en el tratamiento de estas lesiones aunque se requiere una serie más larga y un seguimiento a largo plazo para evaluar adecuadamente los resultados.

There is direct relationship between bone bridge length and coracoclavicular fixation resistance to failure: Biomechanical study in a porcine model.

BACKGROUND: This study aims to evaluate the relation between coracoclavicular resistance to failure and the distance between clavicular tunnels. The hypothesis is that a greater clavicular bone bridge between tunnels achieves a stronger coracoclavicular fixation. METHODS: Descriptive Laboratory Study. Thirty-six (36) coracoclavicular models were constructed utilizing porcine metatarsals. Coracoclavicular stabilizations were performed using a subcoracoid loop fixation configuration through two clavicular tunnels, tied at the clavicle's superior cortex using a locking knot. Models were randomly assigned to 1 of 3 experimental groups of variable bone bridge length between clavicular tunnels: 5 mm, 10 mm, and 15 mm. Each group had 12 models. Fixation resistance was assessed through the ultimate failure point under an axial load to failure trial. Failure patterns were documented. A one-way ANOVA test was used, and a Tukey post hoc as needed (P < 0.05). FINDINGS: Mean strength per bone bridge length: 5 mm = 312 N (Range: 182-442 N); 10 mm = 430 N (Range: 368-595 N); 15 mm = 595 N (Range: 441-978 N). The 15 mm group had a significantly higher ultimate failure point than the other two groups: 5 mm (P < 0.001) and 10 mm (P < 0.001). All fixations systematically failed by a superior cortex clavicle fracture at the midpoint between tunnels. INTERPRETATION: A direct relationship between bone bridge length and coracoclavicular resistance to failure was demonstrated, being the 15 mm length a significantly higher strength construct in a tied loop model.

Cerclaje coracoclavicular y banda de tensión con sutura en el tratamiento de fracturas del tercio externo de la clavícula tipos II y V / Coraco-clavicular loop and tension band suture in type II and type V distal-third clavicle fractures

Resumen: Se han descrito diferentes técnicas quirúrgicas para el tratamiento de las fracturas inestables del tercio distal de la clavícula. Las complicaciones asociadas y la necesidad de retirar los implantes siguen siendo motivo de preocupación. Proponemos una técnica quirúrgica que utiliza suturas de alta resistencia para restaurar la estabilidad vertical y horizontal en las fracturas del tercio distal de la clavícula de tipo II y V de la clasificación de Neer. Esta técnica se ha utilizado en tres casos; dos de tipo V y uno de tipo II. En todos se obtuvo la consolidación ósea y todos reanudaron sus actividades previas a la lesión, incluyendo actividad deportiva, a los seis meses de la cirugía. La técnica de cerclaje coracoclavicular y banda de tensión con sutura es un procedimiento sencillo que permite la estabilización vertical y horizontal de la fractura. Permite obtener buenos resultados clínicos y puede ser una alternativa coste-efectiva eficaz en el tratamiento de estas lesiones aunque se requiere una serie más larga y un seguimiento a largo plazo para evaluar adecuadamente los resultados.

Abstract: Many surgical techniques have been used to address unstable distal third clavicle fractures. Complications and the need for hardware removal are still a concern. We propose a surgical technical using high-strength sutures to restore vertical and horizontal stability in Neer type II and Neer type V distal-third clavicle fractures. It has been used in three cases; two type V and one type II. In all cases, bone healing was achieved uneventfully and all patients resumed their pre-injury activities including sports at six-months postoperatively. The coraco-clavicular loop and tension band suture technique is a simple procedure that allows vertical and horizontal stabilization of the fracture. It achieves good clinical results and it may be a cost-effective alternative to other techniques although a longer series and long-term follow-up is required to adequately assess the results.

[Complex fractures of the clavicles lateral third]. / Fracturas complejas del tercio lateral de la clavícula.

BACKGROUND: Fractures of the lateral third of the clavicle represent 18% of all clavicle fractures. Even though non-displaced fractures can be managed conservatively, displaced fractures have a non-union percentage of 30%. Multiple approaches have been proposed to manage the displaced fractures. The objective of this study was to record the prevalence of fractures of the lateral third of the clavicle with involvement of the clavicular-acromial joint, as well as to briefly review the treatment performed in our center and compare it with the current literature. MATERIAL AND METHODS: Retrospective, cross-sectional, descriptive and observational study, which consisted in a review of the records of patients with a diagnosis of fracture of the lateral third of the clavicle with an injury to the clavicular-acromial joint. RESULTS: Lateral third fractures accounted for 24% of all clavicle fractures. Distribution by sex: 10: 2, men: women. Left shoulder predominance, 8:4. The predominant maneuvers were anatomical plate for the lateral third of the clavicle (50% of the cases), coracoclavicular cerclage technique plus resection of the lateral third of the clavicle (25%), plate hook (8.3%), Mumford combined with Waever/Dunn (8.3%), anchor plus Kirschner rods (8.3%). DISCUSSION: The choice of the appropriate treatment will depend on the type of fracture and specific characteristics of each patient. We suggest the use of the coracoclavicular cerclage technique in cases in which the lateral fragment is multifragmented, irreducible or smaller in size than its osteosynthesis would allow, performing plasty of clavicular and coracoclavicular ligaments.

ANTECEDENTES: Las fracturas del tercio lateral de la clavícula representan 18% de todas las fracturas de clavícula. A pesar de que las fracturas no desplazadas pueden manejarse conservadoramente, las desplazadas tienen un porcentaje de no unión de 30%. Múltiples manejos han sido propuestos para las fracturas desplazadas. El objetivo de este estudio fue registrar la prevalencia de fracturas del tercio lateral de la clavícula con afectación de la articulación acromioclavicular, así como hacer una revisión breve del tratamiento realizado en nuestro centro y compararlo con la literatura actual. MATERIAL Y MÉTODOS: Estudio retrospectivo, transversal, descriptivo y observacional, que consistió en una revisión de los expedientes de los pacientes con diagnóstico de fractura del tercio lateral de la clavícula con lesión de la articulación acromioclavicular. RESULTADOS: Las fracturas del tercio lateral representaron 24% de todas las fracturas de clavícula. Distribución por sexos: 10:2, hombres:mujeres. Predominio: hombro izquierdo, 8:4. Los manejos predominantes fueron placa anatómica para tercio lateral de la clavícula (50% de los casos), técnica de cerclaje coracoclavicular más resección del tercio lateral de la clavícula (25%), placa gancho (8.3%), Mumford combinado con Waever/Dunn (8.3%), ancla más varillas Kirschner (8.3%). DISCUSIÓN: La elección del tratamiento adecuado dependerá del tipo de fractura y las características específicas de cada paciente. Sugerimos el uso de la técnica de cerclaje coracoclavicular en los casos en que el fragmento lateral sea multifragmentado, irreductible o de tamaño menor al que permitiría su osteosíntesis, realizando plastía de ligamentos acromioclaviculares y coracoclaviculares.

Fracturas complejas del tercio lateral de la clavícula / Complex fractures of the clavicle's lateral third

Resumen: Antecedentes: Las fracturas del tercio lateral de la clavícula representan 18% de todas las fracturas de clavícula. A pesar de que las fracturas no desplazadas pueden manejarse conservadoramente, las desplazadas tienen un porcentaje de no unión de 30%. Múltiples manejos han sido propuestos para las fracturas desplazadas. El objetivo de este estudio fue registrar la prevalencia de fracturas del tercio lateral de la clavícula con afectación de la articulación acromioclavicular, así como hacer una revisión breve del tratamiento realizado en nuestro centro y compararlo con la literatura actual. Material y métodos: Estudio retrospectivo, transversal, descriptivo y observacional, que consistió en una revisión de los expedientes de los pacientes con diagnóstico de fractura del tercio lateral de la clavícula con lesión de la articulación acromioclavicular. Resultados: Las fracturas del tercio lateral representaron 24% de todas las fracturas de clavícula. Distribución por sexos: 10:2, hombres:mujeres. Predominio: hombro izquierdo, 8:4. Los manejos predominantes fueron placa anatómica para tercio lateral de la clavícula (50% de los casos), técnica de cerclaje coracoclavicular más resección del tercio lateral de la clavícula (25%), placa gancho (8.3%), Mumford combinado con Waever/Dunn (8.3%), ancla más varillas Kirschner (8.3%). Discusión: La elección del tratamiento adecuado dependerá del tipo de fractura y las características específicas de cada paciente. Sugerimos el uso de la técnica de cerclaje coracoclavicular en los casos en que el fragmento lateral sea multifragmentado, irreductible o de tamaño menor al que permitiría su osteosíntesis, realizando plastía de ligamentos acromioclaviculares y coracoclaviculares.

Abstract: Background: Fractures of the lateral third of the clavicle represent 18% of all clavicle fractures. Even though non-displaced fractures can be managed conservatively, displaced fractures have a non-union percentage of 30%. Multiple approaches have been proposed to manage the displaced fractures. The objective of this study was to record the prevalence of fractures of the lateral third of the clavicle with involvement of the clavicular-acromial joint, as well as to briefly review the treatment performed in our center and compare it with the current literature. Material and methods: Retrospective, cross-sectional, descriptive and observational study, which consisted in a review of the records of patients with a diagnosis of fracture of the lateral third of the clavicle with an injury to the clavicular-acromial joint. Results: Lateral third fractures accounted for 24% of all clavicle fractures. Distribution by sex: 10: 2, men: women. Left shoulder predominance, 8:4. The predominant maneuvers were anatomical plate for the lateral third of the clavicle (50% of the cases), coracoclavicular cerclage technique plus resection of the lateral third of the clavicle (25%), plate hook (8.3%), Mumford combined with Waever/Dunn (8.3%), anchor plus Kirschner rods (8.3%). Discussion: The choice of the appropriate treatment will depend on the type of fracture and specific characteristics of each patient. We suggest the use of the coracoclavicular cerclage technique in cases in which the lateral fragment is multifragmented, irreducible or smaller in size than its osteosynthesis would allow, performing plasty of clavicular and coracoclavicular ligaments.

A combined technique for acromioclavicular reconstruction after acute dislocation - technical description and functional outcomes / Técnica combinada para reconstrução acromioclavicular após luxação aguda - descrição técnica e resultados funcionais

ABSTRACT Objective: This study aims to describe the surgical approach to such injuries and to present the clinical and functional outcomes obtained in a cohort of patients. Methods: This is an observational retrospective study that included 153 patients with acute acromioclavicular joint dislocation, operated between 1999 and 2015. Clinical evaluation included the following outcomes: Constant functional scale, development of complications, time to return to previous work/sport activities, and satisfaction index. The contra-lateral (uninjured) shoulder was used as control in subjective outcomes. Radiological evaluation was performed in order to monitor signs of loss of reduction, degenerative joint changes, and coracoclavicular calcifications. Results: The mean age was 29.20 ± 9.53 (16-71), with a large male predominance (91.5%). Follow-up lasted 55.41 ± 24.87 (12-108) months. The mean Constant score attained was 96.45 ± 4.00 (84-100) on operated shoulders and 98.28 ± 1.81 (93-100) on contralateral ones. Almost all patients (98.69%) were satisfied with the surgical results. Worse outcomes were observed in acromioclavicular joint dislocations of increasing grade (from type III to V, but worse for type IV), both concerning the Constant score and return to work or sport. The overall incidence of complications was considered low, with the most prevalent being Kirschner wire failure and isolated coracoclavicular ligament calcifications. Conclusion: The surgical technique described is an excellent option in the treatment of acute acromioclavicular joint dislocations of Rockwood grades III to V. This is corroborated by the excellent clinical and functional outcomes and the low rate of complications.

RESUMO Objetivo: Descrever a abordagem cirúrgica das luxações acromioclaviculares agudas e apresentar os desfechos clínicos e funcionais obtidos em uma coorte de pacientes. Métodos: Estudo observacional retrospectivo que incluiu 153 pacientes com luxação aguda da articulação acromioclavicular operados entre 1999 e 2015. A avaliação clínica incluiu os seguintes desfechos: escala funcional de Constant, surgimento de complicações, tempo até o retorno ao trabalho ou atividades esportivas e índice de satisfação. O ombro contralateral (não lesionado) foi usado como controle nos resultados subjetivos. Foi feita avaliação radiológica para monitorar sinais de perda de redução, alterações articulares degenerativas e calcificações coracoclaviculares. Resultados: A média de idade foi de 29,20 ± 9,53 (16 a 71), com grande predominância masculina (91,5%). O seguimento durou 55,41 ± 24,87 (12 a 108) meses. A média no escore Constant foi de 96,45 ± 4,00 (84 a 100) nos ombros operados e 98,28 ± 1,81 (93 a 100) nos contralaterais. Quase todos os pacientes (98,69%) ficaram satisfeitos com os resultados da cirurgia. Luxações de articulação acromioclavicular de grau crescente (do tipo III para V, mas principalmente no tipo IV) apresentaram resultados piores, tanto no que diz respeito ao escore de Constant quanto ao retorno ao trabalho ou esporte. A incidência global de complicações foi considerada baixa, as mais prevalentes foram falha do fio de Kirschner e calcificações isoladas do ligamento coracoclavicular. Conclusão: A técnica cirúrgica descrita é uma excelente opção no tratamento de luxações agudas de articulações acromioclaviculares classificadas como graus III a V na escala de Rockwood. Essa conclusão é corroborada pelos excelentes resultados clínicos e funcionais e pela baixa taxa de complicações.

A combined technique for acromioclavicular reconstruction after acute dislocation - technical description and functional outcomes.

OBJECTIVE: This study aims to describe the surgical approach to such injuries and to present the clinical and functional outcomes obtained in a cohort of patients. METHODS: This is an observational retrospective study that included 153 patients with acute acromioclavicular joint dislocation, operated between 1999 and 2015. Clinical evaluation included the following outcomes: Constant functional scale, development of complications, time to return to previous work/sport activities, and satisfaction index. The contra-lateral (uninjured) shoulder was used as control in subjective outcomes. Radiological evaluation was performed in order to monitor signs of loss of reduction, degenerative joint changes, and coracoclavicular calcifications. RESULTS: The mean age was 29.20 ± 9.53 (16-71), with a large male predominance (91.5%). Follow-up lasted 55.41 ± 24.87 (12-108) months. The mean Constant score attained was 96.45 ± 4.00 (84-100) on operated shoulders and 98.28 ± 1.81 (93-100) on contralateral ones. Almost all patients (98.69%) were satisfied with the surgical results. Worse outcomes were observed in acromioclavicular joint dislocations of increasing grade (from type III to V, but worse for type IV), both concerning the Constant score and return to work or sport. The overall incidence of complications was considered low, with the most prevalent being Kirschner wire failure and isolated coracoclavicular ligament calcifications. CONCLUSION: The surgical technique described is an excellent option in the treatment of acute acromioclavicular joint dislocations of Rockwood grades III to V. This is corroborated by the excellent clinical and functional outcomes and the low rate of complications.

OBJETIVO: Este estudo teve como objetivo descrever a abordagem cirúrgica das luxações acromioclaviculares agudas e apresentar os desfechos clínicos e funcionais obtidos em uma coorte de pacientes. MÉTODOS: Trata-se de um estudo observacional retrospectivo que incluiu 153 pacientes com luxação aguda da articulação acromioclavicular operados entre 1999 e 2015. A avaliação clínica incluiu os seguintes desfechos: escala funcional de Constant, surgimento de complicações, tempo até o retorno ao trabalho ou atividades esportivas e índice de satisfação. O ombro contralateral (não lesionado) foi utilizado como controle nos resultados subjetivos. Foi realizada avaliação radiológica para monitorar sinais de perda de redução, alterações articulares degenerativas e calcificações coracoclaviculares. RESULTADOS: A média de idade foi de 29,20 ± 9,53 (16 a 71), com grande predominância masculina (91,5%). O seguimento durou 55,41 ± 24,87 (12 a 108) meses. A média no escore Constant foi 96,45 ± 4,00 (84 a 100) nos ombros operados e 98,28 ± 1,81 (93 a 100) nos contralaterais. Quase todos os pacientes (98,69%) ficaram satisfeitos com os resultados da cirurgia. Luxações de articulação acromioclavicular de grau crescente (do tipo III para V, mas principalmente no tipo IV) apresentaram resultados piores, tanto no que diz respeito ao escore de Constant quanto ao retorno ao trabalho ou esporte. A incidência global de complicações foi considerada baixa, sendo que as mais prevalentes foram falha do fio de Kirschner e calcificações isoladas do ligamento coracoclavicular. CONCLUSÃO: A técnica cirúrgica descrita é uma excelente opção no tratamento de luxações agudas de articulações acromioclaviculares classificadas como graus III a V na escala de Rockwood. Essa conclusão é corroborada pelos excelentes resultados clínicos e funcionais e pela baixa taxa de complicações.

The medial coracoclavicular ligament: anatomy, biomechanics,and clinical relevance-a research study.

BACKGROUND: The medial coracoclavicular ligament (MCCL), is a structure that shows defined morphologic and histologic features. However, little attention has been paid to the MCCL to date. This study was conducted to (1) determine whether the MCCL is a constant structure, (2) analyze its mechanical properties, and (3) determine its possible role in acromioclavicular (AC) stability. METHODS: AC joints, lateral coracoclavicular ligaments (LCCLs; conoid and trapezoid), and MCCLs were dissected in 30 fresh frozen upper limbs. In 6 of these specimens, we performed a sequential sectioning following the aforementioned order. A 20-N cephalad force was applied to the lateral clavicle at each step, recording the AC distance and coracoclavicular space and their variation. In 6 other specimens, we evaluated the anteroposterior motion of the clavicle following the MCCL section. Biomechanical testing was performed in 8 specimens, comparing the resistance of the MCCL to the LCCLs. RESULTS: The MCCL in all of the specimens featured a sharp-edge bundle stretching from the coracoid process to the clavicle and subclavius sheath. It showed ligament-like mechanical properties although less tensile resistance than the LCCLs. Once the AC and LCCLs were sectioned, transection of the MCCL determined a significant increase in both cephalad and posterior displacement. CONCLUSION: The MCCL is a constant structure with the mechanical behavior of a ligament. It may act as the last container of the coracoclavicular space both in cephalad and posterior directions, precluding additional displacement in the absence of the LCCLs.

Identificación del ligamento coracoclavicular medial o de Caldani en imágenes de resonancia magnética: Protocolo original y aplicaciones clínicas / Identification of medial coracoclavicular (Caldani's) ligament by magnetic resonance imaging. Original protocol and clinical applications

Introducción: El ligamento de Caldani o coracoclavicular medial ha sido estudiado anatómicamente, pero no hemos hallado mención alguna sobre su identificación imagenológica. El objetivo de este trabajo es presentar una técnica original de resonancia magnética que hemos desarrollado para identificarlo, y describir las imágenes correspondientes. Materiales y Métodos: Se incluyó a siete voluntarios sin patología de hombro conocida. Se utilizó un resonador magnético Philips Ingenia de una intensidad de campo magnético de 1.5 T, versión 4.1, diámetro de Gantry de 70 cm, bobina específica para hombro de 8 canales con imágenes de alta resolución. Se realizaron las secuencias de búsqueda del ligamento en tres planos. Resultados: El ligamento coracoclavicular medial fue identificado en todos los casos, se extendía oblicuamente desde la apófisis coracoides hasta la clavícula, lo que coincide con las descripciones de la bibliografía anatómica consultada. Tuvo una señal hipointensa en todas las secuencias, lo que indica el poco espacio entre fibras y que corresponde a tejido colágeno compacto. Su longitud promedio fue de 41,15 mm (rango 34-47 mm, desviación estándar 4,40). El espesor promedio fue de 2,11 mm (rango 1,3-3,2 mm, desviación estándar 0,66). Conclusiones: El ligamento coracoclavicular medial se puede observar en imágenes de resonancia magnética mediante la técnica original que describimos. La capacidad de localizarlo y observarlo con este estudio por imágenes abre las puertas a futuras investigaciones sobre su posible papel no solo en las compresiones neurovasculares, sino también en las lesiones traumáticas acromioclaviculares, especialmente en las de tipo V de Rockwood. Nivel de Evidencia: II

Introduction: Although Caldani´s ligament or medial coraco-clavicular ligament has been anatomically studied, we have not found any publication regarding its identification in imaging studies. The aim of this research is to present an original technique to locate the medial coraco-clavicular ligament on magnetic resonance imaging, as well as to describe the pertinent findings. Methods: Seven volunteers without any known shoulder pathology were studied by means of this original protocol. A Philips Ingenia magnetic resonance equipment was used, with a magnetic field intensity of 1,5 T, Gantry diameter: 70 cm, and an 8-channel coil for shoulder study. The sequences to locate the ligament were performed in three planes. Results: This ligament was observed in all cases. Its arrangement was similar to that described in previous anatomical studies. Its origin was at the coracoid process, with an oblique path to reach its insertion at the clavicle. The mean length was 41.14 (range 34-47 mm, standard deviation 4.40). The mean thickness was 2.11 mm (range 1.3-3.2 mm, standard deviation: 0.66). Conclusions: The medial coraco-clavicular ligament can be observed in magnetic resonance images using this original procedure. The ability to display this ligament in magnetic resonance images allows for future investigations on its possible role in both thoracic outlet syndrome and traumatic acromioclavicular dislocations, especially the Rockwood type V. Level of Evidence: II

Articulación coracoclavicular en paciente con cervicobraquialgia / Coracoclavicular joint in a patient with cervicobrachialgy

La articulación coracoclavicular es una rara anomalía del hombro; se describe como una articulación sinovial diartrósica entre la clavícula y el proceso coracoideo. Se presenta el caso de una paciente de 49 años de edad, estomatóloga de profesión, que acudió a consulta por dolor en el hombro derecho, con estudio radiográfico que mostró la existencia de una articulación entre el tubérculo conoideo de la clavícula y la superficie superior de la parte horizontal de la apófisis coracoides de la escápula, que posteriormente, al realizar una vista comparativa del hombro contralateral se confirmó la bilateralidad de la anomalía y se infirió que podía ser la causa del dolor. Posteriormente, en exámenes complementarios realizados por la persistencia y modificación de sus síntomas, se constataron evidencias clínicas de una cervicobraquialgia, se concluyó finalmente, clínica y radiológicamente, como una espondilosis cervical, con presencia de acentuados cambios degenerativos, fundamentalmente a nivel de los espacios C5, C6 y C7, lo cual justificaba su sintomatología. La paciente fue tratada por métodos conservadores intensivos, con una evolución satisfactoria a mediano plazo. La presencia de la articulación coracoclavicular generalmente constituye un hallazgo radiográfico casual, como en este caso, y la variedad sintomática de esta anomalía es excepcional (AU)

The coracoclavicular joint is a rare anomaly of the shoulder; it is described as a diarthrosic synovial joint between the clavicle and the coracoid process. This is a case of a 49-year-old dentist patient who came to the hospital complaining of pain on the right shoulder with an X-ray study that showed an anomalous joint between conoid tubercle of the clavicle and the upper surface of the horizontal part of the coracoid apophysis of the scapula. A comparative shoulder view was done and showed the bilateral presence of the anomaly, making inferences that the pain on the shoulder could be caused by this joint anomaly. Subsequent X-rays of cervical spine were done, due to the persistent pain and they showed marked degenerative changes on C5, C6 and C7 spaces. The final diagnosis was cervical spondylosis. The patient was treated with an intensive conservative treatment and the progressing was satisfactory in midterm period. Coracoclavicular joint is a rare anomalous joint and it was an accidental radiological finding, in this case and in most of the patients. The existence of the coracoclavicular joint is a fortuitous radiographic finding, as it is in this case, and the symptomatic variety of this anomaly is exceptional (AU)

Coracoclavicular and costoclavicular joints at a common juncture: a rare phenomenon / Articulaciones coracoclavicular y costoclavicular en una unión común: un raro fenómeno

Movements at the human shoulder girdle are the result of complex interplay of glenohumeral, acromioclavicular, sternoclavicular and scapulothoracic articulations. Clavicle apart from articulating with the scapula and sternum is also connected with first rib by costoclavicular ligament and with coracoid process by coracoclavicular ligament. At times the area of attachment of these ligaments on clavicle, first rib and scapula show faceted apophysis suggesting the presence of additional diarthrodial articulations. Costoclavicular joint exists between clavicle and first rib and coracoclavicular joint between clavicle and coracoids process. Both these joints are described in the literature, but the concurrent occurrence of them in the same bone has not been reported yet. We found two clavicles, one of right and other of left side, both of them showed faceted apophysis for costoclavicular and coracoclavicular joint simultaneously, which is rare phenomenon.

Los movimientos de la cintura escapular humana son el resultado de la interacción compleja de las articulaciones glenohumeral, acromioclavicular, esternoclavicular y escapulotorácica. La clavícula, aparte de la articulación con la escápula y el esternón también está conectada con la primera costilla por el ligamento costoclavicular y con el proceso coracoides por el ligamento coracoclavicular. A veces la zona de unión de estos ligamentos de la clavícula, la primera costilla y la escápula muestran procesos facetarios que sugieren la presencia de nuevas articulaciones diartrodiales. La articulación costoclavicular existe entre la primera costilla y la clavícula y la articulación coracoclavicular entre la clavícula y proceso coracoides. Ambas articulaciones están descritas en la literatura, pero la aparición simultánea de ellas en el mismo hueso no se ha informado aún. Se encontraron dos clavículas, uno del lado derecho y otra del lado izquierdo, las dos presentaron procesos facetarios para las articulaciones costoclavicular y coracoclavicular simultáneamente, lo cual es un fenómeno raro.