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This is an open access article distributed under the terms of Creative Commons Attribution License. Despite its prevalence, the lack of consensus regarding its diagnosis and treatment makes it one of the most controversial shoulder injuries 2 , 3.
The Rockwood classification system is very important for surgeons to accurately diagnose AC joint injuries and is used in the literature to guide nonoperative vs. However, it remains controversial for type III injury whether to take operative treatment or not. Numerous biomechanical studies in recent years have led to the development of surgical techniques that stabilize the AC joint complex with fixation that more closely approximates the natural anatomic structure 11 — Currently, many operative treatments for type III injury are effective, such as clavicular hook plate fixation CHPF , kirschner wires tension band fixation, reconstruction of coracoclavicular ligaments, and so on 15 — However, the complications of surgery, including looseness of internal fixation, postoperative pain of shoulder, restricted joint motion and recrudescence of joint dislocation after removing internal fixation, is still an important issue 19 — The endobutton technique has been used for patients and is worthy of popularization 30 — But injury to the shoulder was worse.
Compared with hook plate in the treatment of the ACD of Rockwood type III, the endobutton technique showed better short-term results with regard to complications and could be used effectively in the treatment. Biomechanical studies in recent years have demanded stabilization of the AC joint complex with fixation that more closely approximates the natural anatomic structure 34 — 36 , and the double-endobutton technique could be compatible with anatomic structure.
In a clinical study, there were no significant differences in the mean incision length, blood loss, the operative and radiation time, length of hospitalization, the Constant and VAS scores, and ability to return to previous work between a double endobutton group and triple endobutton group, and the triple endobutton treatment had higher hospital costs Hu et al 38 explored the clinical efficacy of double endobutton reconstitution of the coracoclavicular ligament combined with repair of the acromioclavicular ligament in stage I in treating ACD with Rockwood type III—V, which suggested good early results.
In fresh-frozen cadaveric upper extremeties, Struhl et al 39 compared the stability of a novel closed-loop double-endobutton construct with a commercially available cortical button system in both the axial and superior directions and they suggested closed-loop double-endobutton construct provided good stability. In addition, Struhl and Wolfson 40 made a mean follow-up of 5. It was reported that arthroscopy seem to have a lower rate of residual postoperative pain and postoperative recurrence We modified common closed-loop double-endobutton technique by shoulder arthroscopy, which would provide a better treatment for ACD patients.
The application of double-endobutton reconstruction in patients with ACD has significantly reduced the postoperative complications 35 , Also, the effect on Rockwood type III has been confirmed 42 — At the same time, the improvement of double-endobutton reconstruction is always ongoing, aiming at simplifying the surgical procedures, strengthening the internal fixation, and reducing the complications. With the rapid development of arthroscopic technique, we modified common closed-loop double-endobutton technique CCDT to treat ACD by shoulder arthroscopy.
Based on replacement and stabilization of the AC joint, the modified closed-loop double-endobutton technique MCDT was more simple, convenient and efficient than CCDT, and was worth popularizing.
The ACD of Rockwood type III, the coracoclavicular ligament is ruptured completely, the stability of the acromioclavicular joint on the vertical direction is lost, and the distal clavicle is shifted upwards, that causes shoulder joint pain, swelling, and even restricted movement.
The total length of the loops that was made before procedure, was approximately equal to CC-interval in uninjured side shoulder. The modified closed-loop double-endobutton was implanted in injured side by arthroscopy technique, so the ACD of Rockwood type III was restored, and it provided a stable environment, which was beneficial to early activities and recovery. The present study still had some limitations.
For example: Firstly, all cases enrolled were from the same hospital but not a multi-center study. Secondly, the length of the loops was be determined by CC-interval in uninjured side shoulder, which maybe ignore the difference between the left and right side.
Thirdly, the radiographic distance maybe were little erroneous. By comparing the three groups, the advantages of MCDT were known, and it provided evidence and support for clinical extensive application. Cases were enrolled according to such inclusion criteria: i Patients were diagnosed as acute ACD without course of exceeding 7 days before surgical treatment.
Other cases would be excluded with such criteria: i Patients had an injury longer than 7 days before surgery. Informed consent was obtained from all individual participants included in the present study. Each group underwent surgical treatment by one of three types of operations separately.
All surgeries were completed by the same senior surgeons in our hospital. In addition, the main injury reasons contained traffic accident 22 cases , tension injury during exercise 20 cases , falling injury 10 cases and heavy pound injury 3 cases. Meanwhile, operative time, incision lengths and intraoperative hemorrhage were observed as surgical index. First of all, CC-interval of all patients in both shoulders were measured under radiographs Fig.
Then, one of endobuttons' loop was penetrated into another endobutton's loop. Later, the former endobutton was reflected into its own loop which had passed through another endobutton's loop before.
Finally, two endobuttons were strained from two opposite direction, making a closed-loop slipknot between two endobuttons, which was the modified closed-loop double-endobutton Fig. The total length of the loops that was made before was approximately equal to CC-interval in uninjured side shoulder of the same patient.
After that, non-absorption braided tendon sutures Johnson, USA were loaded into the first and fourth holes on plates separately as lead wires. Preoperative radiographs of shoulders of injured side right and uninjured side left.
The CC-interval was vertical distance of the upper edge of clavicle to lower edge of coronoid, was measured from a to d, the interval from b to c increased in the injured side.
In CCDT group, single-endonbutton with a loop was prepared at first. Then non-absorption tendon sutures Johnson, USA were pierced into the first and fourth holes on plates separately as lead wires, which was single-endobutton with a loop Fig. At the same time, the other sutures fixed on the loop. Also another endonbutton without loops was prepared. The diameter of loops was 4. Under general anesthesia in beach chair position, almost with angle of 70 degree between horizontal line and the upper part of the body.
Trunk, limbs and head were fixed and surgical incisions were marked before the procedure Fig. Then, the patients were anesthetized and were sterilized on surgical area. The shoulder joint was examined under anesthesia, and small incisions were made around the joint, the scope and surgical instruments would go into these incisions.
The scope was inserted into the shoulder joint, saline solution flowed through a tube and into the shoulder capsule to expand the joint and to improve visualization.
The image was sent to a video monitor where the surgeon could see inside the joint. Planer tool was inserted from anterior-lateral approach, with the scope was inserted from lateral approach, in order to remove partial plica that could cause pain and to expose clearly coracoid base, the guiding locator Fig.
A hole was drilled in the top of the clavicle midway between the anterior and posterior borders and directly in line with the base of the coracoid, the tunnel was drilled over guide wire with the same diameter as the loop. By using a grasper, the lead wires were inserted from coracoid tunnel into clavicle tunnel and penetrated out the top of clavicle tunnel finally. Then the modified closed-loop double-endobutton would be inserted. One of endobuttons was taken from clavicle tunnel to the base of coracoid tunnel.
While pushing the distal clavicle downwards, the lower endobutton was fixed on the base of coracoid, and the upper endobutton was fixed on the top of clavicle.
Finally ACD was repaired Fig. After that, the lead sutures on endobutton were drawn out, the surgical instruments were removed and the procedure was completed, the proper location of AC joint was confirmed through arthroscopy, the incision was cleaned and sutured finally.
Marked incision, approach of shoulder arthroscopy and guiding locator in the surgical process of MCDT. A The bony marks of coracoid 1 , distal clavicle 2 and acromion 3 and four approaches as anterior-medial a , anterior-lateral b , posterior-lateral c and posterial-medial d were marked; B The guiding locator which would be used in the next stage of surgery.
A One of prepared endobuttons was taken from clavicle tunnel to the base of coracoid tunnel; B By pushing the distal clavicle downwards, the lower endobutton was fixed on the base of coracoid, and the upper endobutton was fixed on the top of clavicle; C Prepared single-endobutton with a loop was taken into base of coracoid tunnel and was fixed on the base of coracoid.
Another single-endobutton without loops was placed in the loop on top of the clavicle; D The loop was locked by two knotted sutures on the single-endobutton without loops. The selection of body position and process of arthroscopic examination and establishing bone tunnel were same as MCDT. Prepared single-endobutton with a loop was taken into base of coracoid tunnel and was fixed on the base of coracoid.
And the loop on the single-endobutton was pulled out clavicle tunnel at the same time, leaving empty place for the single-endobutton without loops. After pushing distal clavicle downwards for qualified reconstruction, the single-endobutton without loops was placed in the loop on top of the clavicle.
Then the loop was locked by two knotted sutures from the second to third and the first to fourth holes on the single-endobutton without loops and the lead sutures from the single-endobutton with a loop was also drawn out Fig.
At the end, the proper location of AC joint was confirmed through arthroscopy, the incisions were cleaned and sutured by layers finally. In supine position, after general anesthesia, patients were made an arc incision from middle part of clavicle to acromion with 7—9 cm, exposing AC joint. Intervening soft tissues were removed in the AC joint and the operative vision were cleared completely later.
Then the prepared plate was moulded as the shape of clavicle, and was inserted on the top of the AC joint. The holes were drilled and the screws were inserted. Finally, the incisions were cleaned and sutured. Operated shoulder was rested in a sling for 4 weeks. Functional exercises were started 3 days after operation. Passive exercises began in 4 weeks. Active movement of the shoulder and resistant exercises were allowed after 4 to 12 weeks.
Strenuous exercises were avoided during first three months following surgery. The time of using injury-side sling and functional exercise were extended for patients whose healing was slow. At first, all patients reviewed clinical postoperative examination at 2, 3, 6 months.
Afterwards, they were required to get follow-up examination every 6 months. The Pearson chi-square test and Fisher exact test were used to compare categorical outcomes. The paired t test was used to compare the functional scores and CC-interval after the operation with those before operation.
And the radiography of patients in three group showed satisfying operative effect after one year Figs. Differences in functional score of shoulder among 3 groups. CHPF group. The radiography of injured shoulders in 3 groups showed satisfying operative effect. It had basically been obtained a consensus that the Rockwood type IV, V and VI injury should be treated with operation.
However, the treatment of type III was still controversial 25 , 49 — Nowadays, it had been put forward more and more high demands to the range of shoulder motion and its flexibility, but there were so much uncertainty and instability about conservative treatment. As a consequence, great emphases were put on the operational treatments 53 — In addition, at present, the CHPF was the commonly recognized operation method with many advantages 56 — 59 , for example, the great histocompatibility, the anatomic design, attaching with distal clavicular, stable fixation, continuously pressurizing distal clavicular, keeping slight activity of AC joint and noninterference in the normal physiological structure of AC joint.
Nevertheless, studies had been reported that the CHPF also showed many complications, including shoulder pain, subacromial inpingement, redislocation after extracting the internal fixation, even a stress fracture, and so on 60 —
Endobutton Button Endoscopic Fixation Technique in Anterior Cruciate Ligament Reconstruction
This is an open access article distributed under the terms of Creative Commons Attribution License. Despite its prevalence, the lack of consensus regarding its diagnosis and treatment makes it one of the most controversial shoulder injuries 2 , 3. The Rockwood classification system is very important for surgeons to accurately diagnose AC joint injuries and is used in the literature to guide nonoperative vs. However, it remains controversial for type III injury whether to take operative treatment or not. Numerous biomechanical studies in recent years have led to the development of surgical techniques that stabilize the AC joint complex with fixation that more closely approximates the natural anatomic structure 11 —
Complications Following Endobutton for Anterior Cruciate Ligament Reconstruction
The subjective and objective clinical results as well as the radiological results tunnel enlargement obtained by a cortical, extra-anatomic femoral fixation are at least equivalent to the results obtained with other types of femoral fixation systems. No additional interference screw was necessary. According to the IKDC laxity classification, Four failures required revision with a patellar tendon graft. The mean value was 1. The results of this series are comparable to the results of other series. This femoral fixation procedure appeared necessary and sufficient to providing good mechanical stability for the graft in the femoral tunnel.