探讨关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位的临床疗效。

回顾性分析上海交通大学医学院附属新华医院骨科采用关节镜辅助下三束重建治疗21例急性Rockwood Ⅲ型肩锁关节脱位患者的资料，均为闭合性损伤。术后3、6、12个月对所有患者进行术后临床效果和影像学评价。根据术后影像学资料评估复位再丢失情况，采用Constant评分和上肢功能（disabilities of arm，shoulder and hand，DASH）评分评估患者肩关节功能。探讨术中关节镜辅助治疗的意义和价值。

术中关节镜探查发现4例合并软组织损伤，并进行一期镜下修复。所有患者术后均未发生喙突骨折和襻断裂。影像学评估提示术后6~12个月有6例患者（28.6%）出现轻度复位丢失，但与Constant评分和DASH评分无显著相关性，没有患者要求取出内固定。

关节镜辅助下三束重建治疗急性Rockwood Ⅲ型肩锁关节脱位是一种创伤小、安全、临床效果确切的手术方法。急性肩锁关节脱位通常由高能量损伤造成，在手术中关节镜探查肩关节能发现合并的软组织损伤，并进行一期修复，有利于肩关节功能的恢复，避免二次手术。

Acromioclavicular joint dislocation is a common shoulder joint injury, which is very common in traffic accidents and contact sports, and there are far more male patients than females. The gold standard for the treatment of acromioclavicular joint dislocation of Rockwood type III has been controversial. Many studies have suggested that Rockwood type III acromioclavicular joint dislocation can achieve better clinical result after conservative treatment, but some studies have found that there are still persistent pain and dysfunction in conservative treatment. Some authors advocate surgical treatment of type III acromioclavicular joint dislocation in young and active patients to restore normal shoulder function. Recent studies have shown that a controlled study of Rockwood type III patients has found that surgical treatment has better function and appearance than conservative treatment. Currently, commonly used hook plate for the treatment of Rockwood type III acromioclavicular joint dislocation, postoperative complications including pain, acromion erosion, subacromial impingement, and the need for secondary surgery to remove implants. Some doctors have achieved good results with Endobutton single-bundle reconstruction. Studies have shown that acromioclavicular joint dislocation often associated with other soft tissue injuries of the shoulder joint. At present, there is no relevant research report on the clinical efficacy of triple bundles reconstruction (cone ligament, oblique ligament, acromioclavicular ligament) assisted by arthroscopy in the treatment of acute Rockwood type III acromioclavicular joint dislocation.

1. General information:This study was included from January 2014 to March 2017. We used triple bundles reconstruction assisted by arthroscopy to treat 21 patients with Rockwood type III acromioclavicular joint dislocation. There were 15 males and 6 females, aged 25-56, mean (34.70 ± 7.25) years old. Causes of injury: 12 cases of traffic injuries, 5 cases of falls, 4 cases of sports injuries. The time from injury to surgery was 1 to 5 days, with an average of (2.7 ± 2.5) days.2. Inclusion and exclusion criteria:Inclusion criteria: (1) Patients with X-ray and CT showed a dislocation of Rockwood type III acromioclavicular joint; (2) closed injury within an injury time of 2 weeks; (3) age≥ 18 years old. Exclusion criteria: (1) Open fractures, multiple fractures, such as shoulder fractures, coracoid fractures, glenoid fractures, etc.; (2) combined with vascular and/or nerve injury; (3) no follow-up data.3. Surgical method:General anesthesia, beach chair position, the shoulder of the affected side was completely freed, and the back and head were safely fixed and protected. After sterile disinfection, the posterior approach of the shoulder joint was established, and the arthroscope entered the shoulder joint to probe the labrum, biceps tendon and rotator cuff. If a combined injury was found, a first-stage repair was performed immediately. Viewing from posterior portal, the under surface of coracoid was prepared from anterior working portal. The arthroscope was transferred to the subacromial space, rotator cuff was explored, and then the soft tissue under the clavicle was cleaned. The broken coracoclavicular ligament was observed and carefully protected and retained.A transverse incision was made above the distal end of the clavicle, about 4 cm. From the acromioclavicular joint to the proximal end of the clavicle 1.5 cm and 4 cm was drilled vertically above the clavicle with a 2.0 mm diameter Kirschner wire respectively. Using the Arthrex acromioclavicular joint locator under the monitoring of the lateral approach arthroscopy, centered at the base of the coracoid, drilled with a 4.0 mm K-wire hollow drill, using Arthrex special guide wire and No. 2 PDS line Fiber tape (Arthrex, USA) pulled the four ends from the coracoid into the tunnel, and the four ends of the two wires were pulled into the two clavicle tunnels and pulled out from the clavicle. Two Fiber tapes were placed under the coracoid with a Dog bone plate (Arthrex, USA) , and the four ends above the clavicle were carefully pulled, and the Dog bone plate was seated firmly under the coracoid. Use the periosteal stripper to force down and forward at the distal end of the clavicle, and at the same time top up the elbow joint to completely recover the acromioclavicular joint and continue to recover the acromioclavicular joint slightly. At this point, a 2.0 mm diameter K-wire was used to drive the distal clavicle from the outside of the shoulder to maintain the reduction. Firmly tighten the four ends of the Fiber tape and puncture the two stencils to the surface of the clavicle. Fix the Fiber tape knot, expose the acromioclavicular joint, find the stump of the acromioclavicular ligament, suture it with mattress-suture, and if the end of the ligament is completely avulsed, the distal end of the clavicle is drilled in the forward and backward direction to the No. 2 Fiber wire. The bone tunnel was sutured and fixed, and the temporary Kirschner wire was pulled out, the shoulder joint was moved, and the C-arm machine was fluoroscopy, the reduction was not lost, and the wound was finally closed layer by layer. 4. Postoperative treatment and evaluation of efficacy: The shoulder was in a sling for protection within 4 weeks after surgery. Passive motion was started within 2 weeks. Pendulum-like movement started after 2 weeks, and gradually started active activity training and strength exercises after 4 weeks step by step. 3 months after surgery resume normal exercise and work. Postoperative follow-up included symptoms such as pain, range of shoulder motion, signs of skin irritation, and subacromial impingement. Constant score was evaluated at 3, 6, and 12 months after surgery. The total score was 100 points: >86 was excellent, 71-85 was good, 56-70 was normal, and ≤50 was poor. The disabilities of arm, shoulder and hand (DASH) score was: 0-25 was excellent, 26-50 was good, 51-75 was moderate, and 76-100 was poor. X-ray of bilateral anterior-posterior, west point view, and bilateral weight-bearing view were taken at the first day after operation and the later follow-up. The Scheibel method was used to measure the reduction score of the acromioclavicular joint: the distance between the acromion and the lateral clavicle (ACD) and the distance between the coracoid and the clavicle (CCD) . ACD was the distance from the medial edge of the acromion to the midpoint of the lateral clavicle. CCD was the vertical distance from the upper edge of the coracoid to the lower edge of the clavicle. The gap increasing by ≤30% from the opposite was defined as a slight reduction loss, and >30% was defined as a severe reduction loss. 5. Statistical processing:The measurement data were expressed as mean±standard deviation. SPSS16.0 software was used for data processing. The Constant score and DASH score of the measurement data were compared by Wilcoxon signed rank sum test. The correlation between reduction loss and Constant score was analyzed by Spearman rank correlation test. P< 0.05 was considered to be statistically significant.

Twenty-one patients were included in this study. The injury to operation time was 1 to 5 days, with an average of (2.7 ± 2.5) days. All patients suffered from closed injuries. The operation time was 85-130 min, average (108.6±16.3) min, and the wounds healed primarily. No infection occurred. The postoperative shoulder functional score and quality of life score at 3, 6, and 12 months after surgery are shown in Table 1. It can be seen from the table that the postoperative scores continue to increase over time. Constant score at 12 months follow-up shows, excellent in 18 cases, good in 2 cases, generally in 1 case, the excellent and good rate was 95.2%; according to DASH score, excellent in 17 cases, good in 2 cases, generally in 2 cases, the excellent rate is 90.5%. Postoperative radiological evaluation is shown in Table 2. One day after surgery, the acromioclavicular joint was well-reduction, and there was no difference compared with the healthy side (P=0.16) , but after 3 months, there was a slight loss of the reduction. There was a 0.9 mm reduction loss in acromioclavicular joint, and 0.8 mm between the coracoid and clavicle more than the healthy side, which is a slight reduction loss, but the displacement is no longer increased with time any more. Moreover, this reduction loss was not significantly associated with Constant score or the DASH score (P= 0.23) . No other complications occurred after the operation, such as deep infection, poor wound healing, coracoid fracture, acromioclavicular joint pain, internal fixation loosening, and no secondary surgery was needed to remove the internal fixation due to patient discomfort.

Arthroscopically assisted triple bundle reconstruction for the treatment of acute Rockwood type III acromioclavicular joint separation is a minimally invasive, safe and clinically effective surgical procedure. Acute acromioclavicular joint separation is often caused by a high-energy injury. During the operation, arthroscopic exploration of the shoulder joint can find the concomitant soft tissue injury and a primary repair can be performed simultaneously, which is beneficial to the recovery of the shoulder joint function and secondary surgery can be avoided.