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The purpose of this research was zu present a navigated image-free augmentation technique zum the acromioclavicular share (ACJ) and coracoclavicular (CC) ligaments and to report the clinical and radiological outcomes.

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From 2013 kommen sie 2018, 35 eligible patients to be treated with our navigated image-free ACJ- and CC-augmentation technique. The average follow-up was 3 years. Follow-up evaluations included die Constant-Murley Score, spatu shoulder value, Taft score, und the acromioclavicular share instability (ACJI) score. Ns patients’ quality von life was assessed using die EuroQol-5D (EQ-5D) questionnaire. In addition, in accordance with die instability criteria, radiographs were evaluated before surgery, ~ surgery, und during follow-up.


Overall, 25 patient (71%) suffered in acute form V disruption, 5 (14%) had a form IV disruption, und 5 (14%) had in acute Rockwood kind IIIb injury. Die mean Constant-Murley Score was 90 (range: 56–100; p = 0.53) on ns injured side, and the median subjective shoulder value was 92% (range: 80–100%). The mean Taft and ACJI noten were 10 (range: 4–12) and 86 (range: 34–100), respectively and the typical EQ-5D was 86 (range: 2–100). Die mean CC difference des the injured side was 4 mm (range: 1.9–9.1 mm) punkt follow-up, i m sorry was not significantly various than that des the stark side (p = 0.06). No fractures an the area des the clavicle or ns coracoid were reported.


The arthroscopic- und navigation-assisted treatment von high-grade ACJ injuries in bei anatomical double-tunnel configuration yields comparable clinical and radiological outcomes as the conventional method using bei aiming device. Specific positioning des the hyperplasia system avoids multiple drillings, which stays clear of fractures.

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Shoulder injuries account for 7% of all sports injuries <1>. Of these, 9% are injuries to the acromioclavicular share (ACJ) <2, 3>. Nearly half of the patients through ACJ injuries (43.5%) room 20–30-year-old males <3>. The mechanism von injury ist typically straight trauma caused über a fall or a blow to the arm in the adducted position <3>. Contact sports, such together rugby or American football, space high-risk activities zum ACJ injuries <4>.

There room a variety von treatment options zum high-grade ACJ injuries <3, 5>. Usual surgical approaches zum reconstructing ns ACJ include repairing die acromioclavicular (AC) complex <6> und reconstructing the coracoclavicular (CC) ligaments <7>. A combination des both techniques ist often recommended <3, 8, 9>. The use von arthroscopic techniques in the surgical treatment des ACJ injuries ist increasing, including die augmentation of the CC ligaments v suture based reconstruction bei a double-tunnel (DT) technique, <10,11,12> which returns favorable clinical outcomes <11, 13>.

A disadvantage des most CC augmentation techniques zu sein that one or much more arthroscopically-assisted drillings von the coracoid are required. Wie man multiple attempts are needed kommen sie find die optimal drill hole position, fractures des the coracoid can occur, <14,15,16,17> resulting in construct failure and poor outcomes <14,15,16>. Navigation-assisted techniques can be used kommen sie avoid lot of drilling attempts <18,19,20,21>. The aim des this research was zu present a navigation-assisted augmentation technique zum the ACJ and CC ligaments und to report the clinical and radiological outcomes des this technique.



Thirty-five continually patients through acute ACJ dislocations that were treated via arthroscopic and navigation-assisted DT actions from 2013 kommen sie 2018 were included bei this retrospective examine <22, 23>. All interventions to be performed by two skilled joint operated doctor using ns same suture system and our hyperplasie technique. All operations whereby done within a period von 2 weeks after the injury. This study was approved by the regional institutional principles committee und follows die principles von the Declaration des Helsinki. Educated written consent was obtained from every patient.

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Surgical technique

A standard diagnostic arthroscopy von the shoulder joint was performed under general anesthesia with the patient in a coast chair position (see Additional file 1). In cases des concomitant glenohumeral injuries, these injuries to be treated first. Following arthroscopy, bei anterior-inferior working portal was created nur above the subscapularis tendon und a lateral viewing portal was developed using the outside-in technique. Next, the subcoracoid space und the base von the coracoid were prepared using a radiofrequency ablation an equipment inserted through the anterior-inferior portal.

A 5-cm sagittal saber incision was made across ns clavicle around 1.5 cm medial to ns ACJ. Ns deltotrapezial fascia was identified, und a T-shaped incision des the fascia was made over die ACJ und lateral clavicle. Ns ACJ was freed from the wrapped soft tissue des the AC capsule and AC ligaments. If severely damaged, ns articular disc was excised. After in open reduction of the ACJ, AC transfixation was performed utilizing a K-wire. The correct reduction des the joint was evaluated using in image intensifier.

Reconstruction of the ligaments

Two holes were drilled in the clavicle weil das the reconstruction of the CC ligament. The first followed the course of die conoid ligament through a 2.4-mm K-wire from ns clavicle to die coracoid, 5 mm medial to ns isometric point of the clavicle, as defined von Rios <24>. Ns target ar was ns posterior side of the coracoid base, 5 mm lateral to die medial boundary. Die second hole complied with the prozess of die trapezoid ligament, beginning 5 mm lateral to die isometric point von the clavicle. Ns target zone weil das the second coracoid kellers was 10 mm anterior to die conoidal tunnel und 5 mm medial to ns medial edge von the coracoid, with the intention of leaving a bony bridge of at the very least 10 mm betwee the tunnels <12, 25>.

An developed optoelectronic system with a corresponding software module was used zum navigation (Trauma 2D 3.1 software, produced by Brainlab AG, Munich, Germany). Reflective markers to be attached to die pointer kommen sie determine that is position and to ns drill sleeve zu navigate die drilling direction. A 3D camera allowed real-time tracking of the drill sleeve an relation to ns pointer. Ns movement von the 2 instruments was controlled in three projections (front, top, und overview), which were displayed on a touchscreen. A digital red line marked the tips of both instruments and showed the target trajectory. The corresponding drilling direction von the sleeve was then compared with ns red line zu reach the corresponding target point. In autopilot was used kommen sie orient die navigated instruments, similar zu its current application bei trauma software program <18, 20>.

After the instruments had actually been calibrated, die tip von the pointer was positioned at ns subcoracoid target area through the anterior-inferior portal under arthroscopic control. Die inserted K-wires were drilled over through a cannulated drill (4.0 mm). Two suture cerclage system (TightRope, Arthrex, Inc., Naples, Florida, USA) were presented into ns CC keller with bei insertion aid (Application Sleeve & Pusher, Arthrex, Inc., USA) until die oval taste could be anchored under die coracoid arch under arthroscopic control. The thread systems were tensioned by alternating tension betwee the 2 implants. Finally, ns threads were tied proximally.

The detached deltoid and trapezius fascia to be anatomically reattached to die lateral clavicle using transosseous sutures (#2 FiberWire, Arthrex, Inc., Naples, Florida, USA), und the finish closure des the fascia was accomplished utilizing a fascia suture (Vicryl size 1, Ethicon, Norderstedt, Germany). The initial T-shaped incision of the AC capsule was closed making use of a 3.5-mm suture anchor (Arthrex, Naples, Florida, USA) on die lateral clavicle. Finally, ns temporary ACJ K-wire transfixation was removed using the image intensifier. Ns upper incision was sutured an layers, und the arthroscopic portals to be closed using standard methods.

Postoperative care

During the immediate postoperative period, ns shoulder was immobilized via an internal rotation sling (shoulder immobilization support, Medi GmbH & Co. KG, Bayreuth, Germany). Patients to be permitted zu perform passive motion exercises up zu a flexion und abduction des 45° for the erste 3 weeks postoperatively and up kommen sie 90° during die subsequent 3 weeks. Active movement practice were permitted beginning in postoperative week 7. Patients were advised kommen sie avoid exercises that stressed the ACJ, such together grasping, pushing, and pulling throughout that time.

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Clinical and radiological evaluation

The clinical testimonial (Fig. 1) consisted von a complete physical examination of both shoulders and several shoulder role evaluations, including the Constant-Murley score (CMS), spatu shoulder value (SSV), Taft score (TF), and acromioclavicular share instability (ACJI) score <11, 26,27,28>. The TF was described by Taft et al. 1987 <26>. It grad results after ~ conservative and surgical treatment des AC joint dislocations. Subcategories room “subjective”(=pain; 4 points), “objective” (=range of motion and strength; 4 points) and “radiologic” (4 points). So, ns maximum score ist 12 points. Points kann sein be subtracted for different symtoms: tenderness zu palpation von the AC-joint, wanne cosmetic results, or crepitation. Pressure measurements to be performed ~ above both shoulders with the aid of in isometric dynamometer (Isobex TM dynamometer, MDS Medical an equipment Solutions AG, Burgdorf, Switzerland). Quality von life was assessed using the EuroQol-5D (EQ-5D) questionnaire <29, 30>.