Acromioclavicular joint dislocation is one of the most common injuries of the shoulder, with direct violent injuries more common, mostly in young people, the incidence of shoulder injuries accounts for about 12%, and its classification often adopts Rockwood classification, type I., II adopts conservative treatment, and type IV.~VI. adopts surgical treatment, however, there is still a controversy on the choice of conservative treatment or surgical treatment for Rockwood type III. Although conservative treatment of acromioclavicular joint dislocation is effective, the dislocation is not reduced and remains in the dislocated position in most patients. In addition, some patients have sequelae of chronic instability and pain. According to statistics, there are more than 75 surgical methods for the treatment of acromioclavicular joint dislocation, including intercoracoclavicular fixation, acromioclavicular fixation, ligament reconstruction, distal clavicle resection, and kinetic muscle transfer techniques.
In order to improve the success rate of acromioclavicular joint dislocation surgery, clavicle hook plate and Endobutton belt loop plate have become important surgical methods for the current clinical treatment of acromioclavicular joint dislocation. In recent years, with the in-depth understanding of the acromioclavicular joint anatomy and the continuous development of arthroscopic technology, arthroscopic Endobutton with loop steel plate has become one of the important surgical procedures for the treatment of shoulder joint dislocation. This article will introduce in detail the clinical treatment effects of three internal fixation methods, namely Nice knot fixation with modified loop plates, Endobutton plates with loops and clavicle hook plates, so as to provide useful guidance for the efficient treatment of patients with acromioclavicular joint dislocation in the future.
1. Improved loop steel plate Nice knot fixation
1. Surgical method:
After successful general anesthesia, supine position. A longitudinal incision of about 4 cm long was made from the coracoid process to the acromioclavicular joint, revealing the acromioclavicular joint, the distal end of the clavicle and the base of the coracoid process, and about 0.5 cm lateral to the medial and medial sides of the middle clavicle and anterior 1/3 of the acromioclavicular joint, respectively, using a 2.5 mm K-wire to establish a bone tract on the clavicle, and introducing No. 1 absorbable threads as traction lines for backup. Disassemble the loop steel plate fixing line and the traction line for later use. The loop steel plate traction line bypasses the base of the coracoid process, and the double-strand fixation line is successively drawn from the medial clavicle bone tract, the base of the coracoid process, and the lateral clavicle bone tract by using the wire crossing technique. The acromioclavicular joint was gradually tightened using the Nice knot until the acromioclavicular joint was slightly over-reduced and fixed by knotting (Fig. 1b). The anterolateral aspect of the distal clavicle was drilled, No. 1 absorbable suture was introduced, and the acromioclavicular ligament and joint capsule posterior to the acromion were repaired according to the figure "8", the incision was flushed, and the suture was layer-by-layer. Postoperative x-rays showed appropriate over-reduction of the acromioclavicular (Fig. 1c).
Fig.1 The patient is a 46-year-old male. 1a: Preoperative anteroposterior X-ray of the shoulder joint showed Rockwood type III dislocation of the right acromioclavicular joint; 1b: Intraoperative fixation lines pass through the loops, and absorbable lines for repairing the coracoclavicular ligament, acromioclavicular ligament and joint capsule are reserved respectively; 1c: Postoperative anteroposterior X-ray showed appropriate over-reduction of the acromioclavicular joint.
2. Advantages:
(1) The fixed strength that the loop steel plate system can provide is 1 345 N, which is much higher than the normal coracoclavicular ligament strength (580 N);
(2) There is no coracoid bony tract, no destruction of the coracoid integrity, and no risk of coracoid fracture;
(3) The use of strip loop steel plate belongs to plane fixation, stress dispersion, and reduces the risk of sinking of loop steel plate;
(4) It was found that the coracoclavicular ligament was loosely located in the clavicle lateral footprint area, and the pyramidal ligament and trapezius ligament footprint area were located 30~45mm and 15~30mm away from the distal clavicle, respectively, so the clavicle bone tract was established about 3cm away from the distal clavicle and about 5mm from the medial and lateral sides, which could be anatomically reconstructed.
(5) Repair the acromioclavicular capsule and acromioclavicular ligament to restore horizontal stability. A number of scholars have confirmed that patients with varying degrees of instability after simple coracoclavicular ligament reconstruction.
(6) Nice knot is a kind of high-tension knot that can slide and self-lock, which can meet the strength required for general fracture fixation, and at the same time, under the external dynamic stress, Nice knot can effectively reduce the elongation of the knot and resist the tension generated during functional exercise.
3. Precautions for operation:
(1) The clavicle tract should be established in the anterior 1/3 area of the clavicle, which can avoid the posterior rotation of the clavicle and the forward displacement of the distal clavicle during the tightening of the Nice node;
(2) The fixed line needs to pass through the base of the coracoid process, if it turns from the body of the coracoid process and passes forward, the clavicle will move forward or the fixed line will slip from the coracoid process during the tightening of the Nice knot;
(3) The acromioclavicular joint should be over-reduced during the tightening of the Nice knot: although the Nice knot can slide and self-lock to reduce the lengthening of the knot, the fixation line will creep with postoperative rehabilitation, resulting in rebound at the distal clavicle.
二 Endobutton带袢钢板
1. Surgical method:
After the patient was successfully anesthetized through brachial plexus block, the patient was placed in a supine position, the affected shoulder was raised, routinely disinfected, a towel was laid, and an incision was made on the extraclavian segment of the affected side, and the skin, subcutaneous tissue, and deep fascia were incised to expose the acromioclavicular joint on the affected side. During the operation, the acromioclavicular joint was dislocated, the lateral end of the clavicle was displaced anteriorly and upward, and the acromioclavicular and coracoclavicular ligaments were ruptured. The hematoma was removed, a hole was drilled dorsally 2cm and 4cm away from the distal clavicle, two locking loop steel plates were placed on the dorsal side, and the high-strength pull wires bypassed the base of the coracoid process, the acromioclavicular joint was reset, the K-wire was temporarily fixed, the reduction of the acromioclavicular joint was satisfactory by fluoroscopy, the high-strength thread on the locking loop steel plate was tightened and knotted, the K-wire was removed, the acromioclavicular joint was repaired, the wound was irrigated with normal saline, and the suture was sutured layer by layer (Fig. 2).
Fig. 2 A is the X-ray of the affected shoulder before surgery, B is the X-ray of the affected shoulder after surgery, and C is the postoperative wound.
2. Advantages:
(1) Endobutton belt loop steel plate can effectively repair and reconstruct the coracoclavicular ligament, and play a good role in promoting the recovery of acromioclavicular joint function.
(2) Endobutton steel plate with loop is minimally invasive, titanium alloy steel plate has good compatibility with human tissues, and does not need to take out internal fixation, which can reduce the pain of patients and make faster postoperative recovery.
3. Precautions:
(1) The selection of the needle insertion point of the supraclavicular tract is very important. The bone tract should be selected at about 3.0~3.5cm away from the acromioclavicular joint, and the needle insertion point should be in the middle of the clavicle cross-section or slightly behind the cross-section.
(2) The perforation site on the coracoid process should be selected at the base root, where the bone is strong and not prone to plate invagination and fracture. The periosteal dissection device should be separated close to the periosteum to the base and the base of the coracoid process should be completely exposed, and the action of this process should be gentle to avoid damaging the nerve and vascular bundle below the anterior and inferior coracoid process.
(3) Repair of acromioclavicular ligament and joint capsular complex, which plays a great role in the lateral horizontal stability of acromioclavicular joint. The acromioclavicular joint should be temporarily immobilized with a K-wire at the beginning of acromioclavicular joint reduction, and the acromioclavicular joint can be strengthened by a knot after the K-wire is removed.
(4) Shoulder CT and circumferential reconstruction examinations are routinely performed before surgery, and X-ray examination of non-displaced fractures at the base of the coracoid process often cannot be reflected. Coracoid fractures, especially in patients with fracture lines at the base of the coracoid process, are contraindicated.
(5) Patients who are older or osteoporosis often cause iatrogenic fractures of the clavicle or coracoid process, which is also a relative contraindication to this procedure.
3. The clavicle hook steel plate is fixed
1. Surgical method:
Have the patient perform the procedure in a supine position while raising the affected shoulders. Open the skin and subcutaneous tissue from acromion to the distal clavicle, and the incision length is 5~8cm, effectively exposing the distal clavicle and the acromioclavicular joint. Exploration reveals a tear in the acromioclavicular joint, which is drilled with a K-wire distal to the clavicle. Inserts a pre-reserved 3.0 absorbable suture to effectively clean the joint cavity and broken soft tissues, cartilage discs and articular cartilage. Depending on the degree of dislocation and the unaffected acromioclavicular joint x-ray, the doctor inserts the hook end tightly against the lower edge of the acromion and inserts it below the acromion at the posterior part of the acromioclavicular joint. Once this is done, place the plate on the upper edge of the distal clavicle. At the same time, the steel plate should be applied to press down the clavicle to achieve the reduction effect. After that, a 3.5 mm diameter screw is used to fully fix the plate above the patient's collarbone. Through the reduction examination, it is determined that the fixation is satisfactory and the reserved suture is applied. Effectively repairs the acromioclavicular ligament and immobilizes it at the distal end of the clavicle. At the same time, the damaged coracoclavicular ligament and joint capsule are repaired, and the incision is closed. After the patient completes the operation, the affected limb should be suspended with a triangular scarf. After 1 week, passive shoulder movement can be initiated. If the patient is pain tolerant, active activity may be performed. It is important to note that the outreach should be below 90°. Full functional exercises were performed after 1 month.
2. Advantages and disadvantages:
(1) The advantage of this method is that the opening of the surgical area for the patient is less damaged, so it will not affect the blood supply around the shoulder joint. In addition, the cost of the procedure is relatively low, and it is easily accepted by patients.
(2) However, it is worth mentioning that in the process of treating patients with this method, the fixation is usually unstable when the shoulder joint is dislocated, which in turn causes re-injury to the joint.
(3) The main complication is the postoperative pain of the shoulder joint in the treatment of the hook steel plate, and the analysis of the cause is that the steel plate is not shaped enough during the operation, which causes the excessive pressure of the steel plate hook under the acromion to the acromion upward, and some patients have the phenomenon of hook plate breakage, which increases the difficulty of removing the steel plate in the second operation.
bibliography
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