皇甫小橋 趙金忠 何耀華 楊星光 劉旭東 劉聞欣 王海明

通訊作者：趙金忠,Email:zhaojinzhong@vip.163.com

【摘要】目的研究關(guān)節(jié)鏡下縫線鋼板增強(qiáng)喙鎖韌帶術(shù)治療肩鎖關(guān)節(jié)脫位的近期治療效果。方法2010年3月至2011年3月，在關(guān)節(jié)鏡下使用膝關(guān)節(jié)韌帶重建技術(shù)的縫線鋼板(德國ASCULAP公司，B′BRAUN)增強(qiáng)重建喙鎖韌帶(三角韌帶與斜方韌帶)，治療Rockwood Ⅲ型9例、Ⅴ型3例新鮮肩鎖關(guān)節(jié)脫位。術(shù)后行X線片檢查，以美國肩肘關(guān)節(jié)外科醫(yī)師(America Shoulder Elbow Surgeons，ASES)評分法和Constant評分法評估療效。術(shù)后隨訪12～18個(gè)月。結(jié)果12例患者ASES評分：術(shù)前28.7分，術(shù)后86.9分；Constant評分：術(shù)前24分，術(shù)后91分。治療組X線片顯示，肩鎖關(guān)節(jié)復(fù)位良好。術(shù)后1年，91.7%(11/12)病例獲得滿意治療效果，83.3%(10/12)恢復(fù)到術(shù)前運(yùn)動(dòng)水平，僅有1例出現(xiàn)肩鎖關(guān)節(jié)半脫位。結(jié)論關(guān)節(jié)鏡下縫線鋼板喙鎖韌帶增強(qiáng)術(shù)治療肩鎖關(guān)節(jié)脫位，早期可以獲得滿意的治療效果，術(shù)后復(fù)位良好，并發(fā)癥少。

【關(guān)鍵詞】 肩鎖關(guān)節(jié)脫位； 喙鎖韌帶； 關(guān)節(jié)鏡

【Abstract】BackgroundAcromioclavicular joint dislocation is commonly seen in shoulder joint injuries. Dysfunction as well as pain and discomfort usually occurred when the integrity of shoulder is damaged, for the acromioclavicular (AC) joint is involved in the connection between the scapula and the body as well as the activities of shoulder joint. Therefore, a consensus has been reached to treat severe AC joint dislocation by surgery. Based on different anatomical and functional cognition, methods for AC joint dislocation are various, which are typically performed by incision to reconstruct its stability and restore function. Attempts had been made by many doctors in the reconstruction of AC joint dislocation with the development of arthroscopy. From March 2010 to March 2011, obvious therapeutic effect was obtained in treating Rockwood type Ⅲ and Ⅴ AC joint dislocation arthroscopically with the suture plate used for the reconstruction of ligaments of knee joint to augment the reconstructed CC ligaments (conoid ligament and trapezoid ligament).MethodsFrom March 2010 to March 2011, nine patients with acute AC joint dislocation type Ⅲ and three patients with type V were treated arthroscopically to augment the reconstructed CC ligaments (conoid ligament and trapezoid ligament) by the suture plate (ASCULAP Company, Germany, B′Braun) used to reconstruct ligaments of knee joint. Patients were pre and postoperatively evaluated with X-ray examinations, American Shoulder and Elbow Surgeons′ Form (ASES) and Constant-Murley Score (CMS).ResultsAll 12 patients were followed up for at least 12 months (range,12 to 18 months). The average ASES score significantly increased from 28.7 preoperatively to 86.9 postoperatively, and the mean CMS score from 24 to 91, respectively. X-ray data showed a good reduction of the AC joint in the treated group. 91.7% of patients (11 patients) obtained an obvious therapeutic effect after operation. 83.3% of patients (10 patients) returned to their pre-injury level of athletics. Acromioclavicular subluxation was only found in one case.DiscussionAC joint dislocation usually appears in youth and adults with obvious traumatic history, and often results from the direct violence on the adducted shoulder. The stable structure of AC joint is achieved by the connection between the scapula and the clavicle, and the integrity of the sternoclavicular articulation and the scapulothoracic joint. According to the injury level of acromioclavicular stability, AC joint injuries can be classified into six types by Rockwood, type Ⅲ、Ⅳ、Ⅴ、Ⅵ should be fixed through operation for its disruption of stable structures.The goal of surgical procedure on AC joint dislocation is to reconstruct its anatomy and function. Activity of AC joint and its postoperative rehabilitation training will be inevitably affected by any operation of strict limitation on its flexibility. Arthroscopically assisted augmentation of reconstructed CC ligaments with the suture plate button technique is an effective method in treating AC joint dislocation, which restores its anatomy and has advantages over the traditional open surgery.(1)AC joint anatomy and dislocation of classification:AC joint dislocation often occurs in youth and adults trauma, and is usually caused by direct violence on the adducted shoulder. The connection between the scapula and the clavicle, and the integrity of the sternoclavicular articulation and the scapulothoracic joint can help to achieve the stable structure of AC joint, the former of which is the most important. Coracoclavicular ligament (conoid ligament and trapezoid ligament ), the deltoid and trapezius muscle fascia as well as AC joint are involved in the connection between the scapula and the clavicle. Therefore, functionally speaking, the conception of AC joint should be replaced by acromioclavicular connection. When aforementioned anatomical structure cannot be fixed after AC joint dislocation, the connection between the scapula and the clavicle should be restored or reconstructed. And there is no necessity to emphasize the restoration of the anatomical integrity.According to the injury level of acromioclavicular stability, AC joint juries are classified into six types by Rockwood, type I and II of which are only acromioclavicular joint ligament injuries without complete dislocation. Except complete dislocation, AC joint stability of type Ⅲ and above with severe damages of other joints and soft tissues should be fixed through operation to restore the stable structures.(2)Treatment of AC joint dislocation:The goal of surgical procedure on AC joint dislocation is to reconstruct its anatomy and function. AC joint is involved in the shoulder activity of abduction, flexion and extension. The scapula rotates around anteroposterior axis when shoulder joint abducts over 60 degrees, and AC joint is involved in the activity when the upper arm anteflexes to 90 degrees. Corresponding reflects of AC joint and sternoclavicular articulation are due to the relative rotation around the body at any angle by the scapula. Large movement of AC joint is involved in the normal shoulder exercise, and activity of AC joint and its post operative rehabilitation training will be inevitably affected by any operation of strict limitation on its flexibility such as AC joint Kirschner pin fixation, Coracoclavicular screw fixation and clavicular hook plate. Internal fixation failure results from its abnormal stress caused by the increased range of the shoulder movement. Hence, reliable clavicle reduction should be achieved by clavicle fixation of AC joint or the scapula and the clavicle, while the relative freedom of movement between the scapula and the clavicle should be maintained. Soft fixation between coracoid and clavicle, such as suture, artificial ligament or wire, may be a better choice.Based on the development of arthroscopy, minimally invasive or arthroscopic surgical procedure of shoulder joint has been evolved from open reduction and internal fixation. Minimally invasive surgery had been conducted by some doctors to treat AC joint, and obvious therapeutic effect is achieved through arthroscopic reconstruction of CC ligaments.(3)Advantages of the arthroscopic technique in treating AC joint dislocation:Compared to traditional open surgery, arthroscopically assisted augmentation of reconstructed CC ligaments with the suture plate button technique has advantages as follows:(1) minimal trauma. Just three 5-mm small incisions are needed as arthroscopic pathways to expose the coracoclavicular joint without the alteration of the tissues nearby, which helps for the postoperative rehabilitation. (2) Reliable reduction may be attained arthroscopically without necessary intraoperative X-ray confirmation, which shortens the operation time. (3) The suture plate with good biocompatibility augments CC ligaments and has no effect on AC joint anatomy, which is propitious to healing of the fresh joint capsule and the ligament. (4) The flexible anatomic enhanced fixation allows certain ranges of AC joint movement during abduction, flexion and extension of shoulder, which conforms to the biological nature of AC joint.Long learning of the arthroscopic skills is required due to its key role in the arthroscopically assisted augmentation of reconstructed CC ligaments. Additionally, such anatomical structures as coracoid base, AC joint and CC ligament should be known well. While establishing bone tunnel from the clavicle to the coracoid root, arthroscopy travels along the CC ligament to guarantee the uniformity of cortical bone around the tunnel. After arthroscopic reduction, the plate should be carefully fixed in the end of coracoidprocess to avoid rarefaction of bone that loosens fixation, breaks it off and thus leads to failure.In addition, arthroscopically assisted augmentation of the reconstructed CC ligaments is applicable for patients of type Ⅲ and Ⅴ in Rockwood classification. Open surgery is necessary to restore the stability of joint for type Ⅵ and Ⅳ patients with reduction difficulties.ConclusionsAugmentation of CC ligaments with the suture to restore the anatomy of AC joint is an effective method in treating the dislocation. Minimal injury, reliable reduction of AC joint, less complication and rapid recovery of the shoulder joint function are found after the arthroscopic operation. Whether AC joint structure is stabilized and its biomechanic features are self-repaired to restore the normal anatomy and function or not, which required long term follow-up.

【Keywords】 Acromioclavicular joint dislocation； Coracoacromial ligament； Arthroscopy

肩鎖關(guān)節(jié)脫位在肩關(guān)節(jié)外傷中比較多見，因肩鎖關(guān)節(jié)既參與肩胛骨和軀干的連接，也參與肩關(guān)節(jié)的活動(dòng)，當(dāng)肩鎖關(guān)節(jié)的完整性遭到破壞時(shí)，常引起各種肩部疼痛、不適和肩關(guān)節(jié)功能障礙。因此，對于嚴(yán)重的肩鎖關(guān)節(jié)脫位，采用手術(shù)治療已成為共識。基于對肩鎖關(guān)節(jié)解剖結(jié)構(gòu)以及功能認(rèn)識的不同，治療肩鎖關(guān)節(jié)脫位的方法各不相同，一般通過切開重建其穩(wěn)定結(jié)構(gòu)，以恢復(fù)關(guān)節(jié)的功能[1]。近來隨著關(guān)節(jié)鏡器械技術(shù)的發(fā)展，許多學(xué)者嘗試關(guān)節(jié)鏡下重建喙鎖韌帶治療肩鎖關(guān)節(jié)脫位[2-7]。2010年3月至2011年3月，我們在關(guān)節(jié)鏡下使用膝關(guān)節(jié)韌帶重建技術(shù)的縫線鋼板，解剖增強(qiáng)重建喙鎖韌帶(錐形韌帶與斜方韌帶)治療RockwoodⅢ、Ⅴ型肩鎖關(guān)節(jié)脫位，取得良好效果。

臨床資料

一、一般資料

本組急性肩鎖關(guān)節(jié)脫位12例，其中女性4例，男性8例；右肩9例，左肩3例；年齡17～43歲，平均37歲。按照Rockwood分類，肩鎖關(guān)節(jié)脫位Ⅲ型9例，Ⅴ型3例。均在關(guān)節(jié)鏡下行縫線鋼板技術(shù)增強(qiáng)喙鎖韌帶，手術(shù)時(shí)間為外傷后1～12 d，平均5 d。術(shù)后系統(tǒng)隨訪12～18個(gè)月。

二、術(shù)前準(zhǔn)備

術(shù)前常規(guī)攝肩鎖關(guān)節(jié)正位X線片確定脫位的類型(圖1A)。RockwoodⅣ、Ⅴ、Ⅵ型肩鎖關(guān)節(jié)脫位通過肩關(guān)節(jié)正位X線片，結(jié)合檢查即可確診；為避免將RockwoodⅢ型肩鎖關(guān)節(jié)脫位誤診為Ⅱ型，需要在應(yīng)力狀態(tài)下，攝肩關(guān)節(jié)正位X線片進(jìn)行診斷。為排除肩峰下其他病變，有時(shí)需要進(jìn)行岡上肌出口位X線片或者肩關(guān)節(jié)MRI檢查。

三、手術(shù)方法

本組病例均行臂叢神經(jīng)肌間溝神經(jīng)阻滯、氣管插管、全身麻醉，成功后擺放體位，取側(cè)臥患肢懸吊位?；技缂吧现緹o菌巾單包裹。術(shù)前對患肩進(jìn)行全面檢查，用無菌筆作鎖骨、肩峰與喙突輪廓的解剖標(biāo)記，注意標(biāo)記肩鎖關(guān)節(jié)間隙中點(diǎn)。術(shù)前在鎖骨走行肩鎖關(guān)節(jié)近端3 cm處以尖刀做一小切口，采用標(biāo)準(zhǔn)肩關(guān)節(jié)鏡手術(shù)后方入路，進(jìn)入盂肱關(guān)節(jié)行關(guān)節(jié)腔內(nèi)檢查，經(jīng)前方入路伸進(jìn)汽化電刀清理，顯露喙突基底。

然后通過后方入路進(jìn)入肩峰下隙，取外側(cè)入路使用汽化電刀和刨刀清理肩峰下隙滑膜組織，檢查肩鎖關(guān)節(jié)脫位情況，沿鎖骨向近端清理顯露鎖骨下緣到喙鎖韌帶。

然后關(guān)節(jié)鏡后方進(jìn)入盂肱關(guān)節(jié)，在關(guān)節(jié)鏡監(jiān)視下，從前方入路伸進(jìn)膝關(guān)節(jié)前交叉韌帶(Anterior Cruciate Ligament, ACL)重建定位器，勾住喙突基底處(圖1B)。通過術(shù)前鎖骨切口標(biāo)記處用2.5 mm克氏針建立骨隧道導(dǎo)向針。進(jìn)入喙突基底后，此時(shí)關(guān)節(jié)鏡進(jìn)入肩峰下隙，觀察導(dǎo)向克氏針鎖骨下面位置。保證導(dǎo)向針從鎖骨中間穿過到喙突基底。然后使用4.5 mm鉆頭順導(dǎo)向針建立喙鎖增強(qiáng)隧道(圖1C)。

然后從鎖骨端隧道把牽引鋼絲伸進(jìn)喙突基底，關(guān)節(jié)鏡監(jiān)視下把帶鋼板的增強(qiáng)帶牽出鎖骨端，鋼板置于喙突基底(圖1D)。關(guān)節(jié)鏡肩峰下觀察肩鎖關(guān)節(jié)完全復(fù)位后，在鎖骨端行增強(qiáng)帶紐扣固定(圖1E)。手術(shù)完畢，關(guān)節(jié)鏡再次觀察喙突基底鋼板位置以及肩鎖復(fù)位情況。

術(shù)中僅使用30°關(guān)節(jié)鏡頭，縫線鋼板為BRAUN前交叉韌帶重建包。

四、術(shù)后處理

術(shù)后前2周休息時(shí)用頸腕吊帶制動(dòng)，盡早行上肢被動(dòng)前屈和外旋等功能鍛煉，但前屈幅度不宜超過90°，4周后開始主動(dòng)前屈、外展及外旋功能鍛煉。前屈和外展幅度盡可能達(dá)到180°，6周后開始進(jìn)行肩關(guān)節(jié)各種抗阻力練習(xí)，術(shù)后12周行各種體力活動(dòng)或者運(yùn)動(dòng)。

五、評價(jià)方法

術(shù)后定期攝X線片，了解肩鎖關(guān)節(jié)維持復(fù)位情況(圖1F、G)，以及有無其他異常變化。按照ASES評分標(biāo)準(zhǔn)與Constant[2]評分。術(shù)后6周，3、6、12個(gè)月各評估一次。

六、統(tǒng)計(jì)學(xué)分析方法

用SPSS統(tǒng)計(jì)學(xué)軟件包進(jìn)行數(shù)據(jù)分析，治療前、后療效對比采用自身配對t檢驗(yàn)，以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

12例肩鎖關(guān)節(jié)脫位患者ASES評分：術(shù)前28.7分，術(shù)后86.9分；Constant評分：術(shù)前24分，術(shù)后91分。治療組X線片顯示，肩鎖關(guān)節(jié)復(fù)位良好，僅有1例出現(xiàn)肩鎖關(guān)節(jié)半脫位。術(shù)后1年，91.7%(11/12)病例獲得滿意治療效果，83.3%(10/12)恢復(fù)到術(shù)前運(yùn)動(dòng)水平。

討 論

一、肩鎖關(guān)節(jié)結(jié)構(gòu)及其脫位分類

肩鎖關(guān)節(jié)脫位多發(fā)生于青壯年，有明確的外傷史，常常直接暴力作用于內(nèi)收的肩關(guān)節(jié)所致。肩鎖關(guān)節(jié)的穩(wěn)定性靠包括肩胛骨和鎖骨之間的連續(xù)，胸鎖關(guān)節(jié)和肩胸關(guān)節(jié)的完整性來實(shí)現(xiàn)，其中肩胛骨和鎖骨之間的連接最為重要。肩胛骨和鎖骨之間的連接不僅包括肩鎖關(guān)節(jié)，還包括喙鎖韌帶(椎狀韌帶及斜方韌帶)以及三角肌-斜方肌筋膜。因此，從功能上講，應(yīng)當(dāng)以肩鎖連接的概念取代肩鎖關(guān)節(jié)。當(dāng)肩鎖關(guān)節(jié)脫位后上述解剖結(jié)構(gòu)不能修復(fù)時(shí)，只要能恢復(fù)或者重建肩胛骨和鎖骨之間的可靠連接即可，不必過于強(qiáng)調(diào)恢復(fù)肩鎖關(guān)節(jié)的解剖學(xué)完整性[7-10]。

根據(jù)肩鎖穩(wěn)定結(jié)構(gòu)的損傷情況，Rockwood把肩鎖脫位分為6型，其中Ⅰ、Ⅱ 型損傷僅僅為肩鎖關(guān)節(jié)韌帶損傷，未出現(xiàn)關(guān)節(jié)的完全脫位，一般采用非手術(shù)療法。Ⅲ 型及Ⅲ 型以上的損傷，除肩鎖關(guān)節(jié)完全脫位外，尚伴有其他關(guān)節(jié)結(jié)構(gòu)及周圍軟組織損傷較重，這些情況破壞了關(guān)節(jié)穩(wěn)定結(jié)構(gòu)，需要通過手術(shù)恢復(fù)肩鎖關(guān)節(jié)的穩(wěn)定性。

二、肩鎖關(guān)節(jié)脫位的治療

肩鎖關(guān)節(jié)脫位進(jìn)行外科手術(shù)的目的，就是要進(jìn)行解剖和功能的重建。肩鎖關(guān)節(jié)主要參與肩關(guān)節(jié)展收和屈伸活動(dòng)。肩關(guān)節(jié)外展超過60°即出現(xiàn)肩胛骨圍繞矢狀軸旋轉(zhuǎn)，上臂前屈至90°即有肩鎖關(guān)節(jié)活動(dòng)參與。肩胛骨與軀體間的任何角度的相對旋轉(zhuǎn)活動(dòng)，都通過肩鎖關(guān)節(jié)和胸鎖關(guān)節(jié)有相應(yīng)的反應(yīng)。正常肩關(guān)節(jié)活動(dòng)涉及肩鎖關(guān)節(jié)較大的活動(dòng)，任何嚴(yán)格限制肩鎖關(guān)節(jié)活動(dòng)的手術(shù)，如肩鎖關(guān)節(jié)克氏針內(nèi)固定、喙鎖間螺釘內(nèi)固定、鎖骨鉤鋼板都必然影響肩關(guān)節(jié)的活動(dòng)[11-15]，從而影響術(shù)后肩關(guān)節(jié)的康復(fù)訓(xùn)練。由于在肩關(guān)節(jié)活動(dòng)幅度稍大時(shí)，內(nèi)固定即承受異常應(yīng)力，易導(dǎo)致內(nèi)固定失敗。因此肩鎖關(guān)節(jié)，或肩胛骨與鎖骨間的固定既要達(dá)到鎖骨可靠的復(fù)位，也必須保持肩胛骨與鎖骨間的相對活動(dòng)自由。喙突與鎖骨間的軟性固定，如縫線、人工韌帶或鋼絲固定就成為較好的選擇[16-19]。

近年來隨著微創(chuàng)關(guān)節(jié)鏡技術(shù)的發(fā)展，對于肩關(guān)節(jié)切開內(nèi)固定手術(shù)方式已逐漸發(fā)展為微創(chuàng)小切口或者關(guān)節(jié)鏡下手術(shù)方式，有學(xué)者應(yīng)用肩關(guān)節(jié)鏡下微創(chuàng)術(shù)式，行喙鎖韌帶重建術(shù)治療肩鎖關(guān)節(jié)脫位，取得良好效果[20-27]。

三、關(guān)節(jié)鏡技術(shù)治療肩鎖關(guān)節(jié)脫位的手術(shù)優(yōu)點(diǎn)

關(guān)節(jié)鏡下使用縫線鋼板紐扣技術(shù)，行喙鎖韌帶增強(qiáng)重建術(shù)治療肩鎖關(guān)節(jié)脫位，與傳統(tǒng)切開方法比較，有其明顯的優(yōu)點(diǎn)：(1)手術(shù)創(chuàng)傷小。關(guān)節(jié)鏡手術(shù)僅僅需要3個(gè)5 mm小切口作為手術(shù)的通路完成，僅顯露喙鎖關(guān)節(jié)，對周圍穩(wěn)定結(jié)構(gòu)沒有干擾，便于術(shù)后的康復(fù)；(2) 關(guān)節(jié)鏡監(jiān)視下復(fù)位可靠，不需要術(shù)中X線確認(rèn)，縮短了手術(shù)時(shí)間；(3) 縫線鋼板生物相容性好，增強(qiáng)喙鎖韌帶，對肩鎖關(guān)節(jié)解剖結(jié)構(gòu)沒有影響，有利于新鮮關(guān)節(jié)囊及韌帶的修復(fù)愈合；(4) 解剖位增強(qiáng)固定屬于彈性固定，在肩關(guān)節(jié)展收屈伸活動(dòng)中允許肩鎖關(guān)節(jié)有一定的活動(dòng)度，符合肩鎖關(guān)節(jié)的生物特性。

使用關(guān)節(jié)鏡技術(shù)增強(qiáng)重建喙鎖韌帶，首先關(guān)節(jié)鏡操作技術(shù)必須熟練，因此需要較長學(xué)習(xí)曲線；此外術(shù)中需要熟悉鏡下喙突基底、肩鎖關(guān)節(jié)以及喙鎖韌帶的解剖結(jié)構(gòu)；在建立鎖骨到喙突根部骨隧道時(shí)，沿喙鎖韌帶方向走行，關(guān)節(jié)鏡顯示保證隧道周圍骨皮質(zhì)均勻；關(guān)節(jié)鏡下復(fù)位后固定時(shí)加強(qiáng)喙突端的鋼板固定，避免因骨質(zhì)疏松，出現(xiàn)固定鋼板松動(dòng)脫落，導(dǎo)致手術(shù)失敗。

此外關(guān)節(jié)鏡下行喙鎖韌帶增強(qiáng)重建技術(shù)適合Rockwood Ⅲ、V型患者，對于難以復(fù)位的Ⅵ、Ⅳ型脫位，則需要通過切開手術(shù)恢復(fù)關(guān)節(jié)的穩(wěn)定。總之，通過縫線增強(qiáng)喙鎖韌帶結(jié)構(gòu)，恢復(fù)肩鎖關(guān)節(jié)解剖位置，是治療肩鎖關(guān)節(jié)脫位的一種有效方法。關(guān)節(jié)鏡下手術(shù)操作創(chuàng)傷小，肩鎖關(guān)節(jié)復(fù)位可靠，并發(fā)癥少，肩關(guān)節(jié)功能恢復(fù)快。但能否使肩鎖關(guān)節(jié)穩(wěn)定結(jié)構(gòu)及其生物力學(xué)特點(diǎn)自行修復(fù)，恢復(fù)其正常的解剖結(jié)構(gòu)功能，還需要更長期的隨訪觀察。

參 考 文 獻(xiàn)

[1] Weaver JK, Dunn HK.Treatment of acromioclavicular injuries, especially complete acromioclavicular separation.J Bone Joint Surg Am,1972,54(6):1187-1194.

[2] Michlitsch MG, Adamson GJ, Pink M,et al.Biomechanical comparison of a modified Weaver-Dunn and a free-tissue graft reconstruction of the acromioclavicular joint complex.Am J Sports Med,2010,38(6):1196-203.

[3] Lewicky YM, Robertson CM, Foran JR. Anatomic coracoclavicular and acromioclavicular ligament Reconstruction for high-grade acromioclavicular separations:the gracilis weave. Orthopedics,2010,33(3):166-171.

[4] Yoo JC, Ahn JH, Yoon JR, et al. Clinical results of single-tunnel coracoclavicular ligament Reconstruction using autogenous semitendinosus tendon. Am J Sports Med,2010,38(5):950-957.

[5] Tauber M, Gordon K, Koller H,et al.Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases:a prospective comparative study.Am J Sports Med,2009,37(1):181-190.

[6] Cohen G, Boyer P, Pujol N,et al.Endoscopically assisted reconstruction of acute acromioclavicular joint dislocation using a synthetic ligament. Outcomes at 12 months.Orthop Traumatol Surg Res,2011,97(2):145-151.

[7] Wei HF, Chen YF, Zeng BF, et al. Triple endobuttton technique for the treatment of acute complete acromioclavicular joint dislocations:preliminary results. Int Orthop,2011,35(4):555-559.

[8] Salzmann GM, Walz L, Buchmann S, et al.Arthroscopically assisted 2-bundle anatomical reduction of acute acromioclavicular joint separations.Am J Sports Med,2010,38(6):1179-1187.

[9] El Shewy MT, El Azizi H. Suture repair using loop technique in cases of acute complete acromioclavicular joint dislocation. J Orthop Traumatol,2011,12(1):29-35.

[10] Chernchujit B, Tischer T, Imhoff AB. Arthroscopic Reconstruction of the acromioclavicular joint disruption:surgical technique and preliminary results. Arch Orthop Trauma Surg,2006,126(9):575-581.

[11] Choi SW, Lee TJ, Moon KH, et al. Minimally invasive coracoclavicular stabilization with suture anchors for acute acromioclavicular dislocation. Am J Sports Med,2008,36(5):961-965.

[12] Zooker CC, Parks BG, White KL,et al.TightRope versus fiber mesh tape augmentation of acromioclavicular joint reconstruction:a biomechanical study.Am J Sports Med,2010,38(6):1204-1208.

[13] DeBerardino TM, Pensak MJ, Ferreira J, et al. Arthroscopic stabilization of acromioclavicular joint dislocation using the AC graftrope system. J Shoulder Elbow Surg,2010,19(2 Suppl):47-52.

[14] Yoo YS, Tsai AG, Ranawat AS,et al.A biomechanical analysis of the native coracoclavicular ligaments and their influence on a new reconstruction using a coracoid tunnel and free tendon graft.Arthroscopy,2010,26(9):1153-1161.

[15] Lafosse L, Baier GP, Leuzinger J.Arthroscopic treatment of acute and chronic acromioclavicular joint dislocation.Arthroscopy,2005,21(8):1017.

[16] Rolla PR, Surace MF, Murena L. Arthroscopic treatment of acute acromioclavicular joint dislocation. Arthroscopy,2004,20(6):662-668.

[17] Wolf EM, Pennington WT. Arthroscopic Reconstruction for acromioclavicular joint dislocation. Arthroscopy,2001,17(5):558-563.

[18] Murena L, Vulcano E, Ratti C,et al.Arthroscopic treatment of acute acromioclavicular joint dislocation with double flip button.Knee Surg Sports Traumatol Arthrosc,2009,17(12):1511-1515.

[19] Yoo YS, Seo YJ, Noh KC, et al. Arthroscopically assisted anatomical coracoclavicular ligament Reconstruction using tendon graft. Int Orthop,2011,35(7):1025-1030.

[20] Elhassan B, Ozbaydar M, Diller D, et al. Open versus arthroscopic acromioclavicular joint resection:a retrospective comparison study. Arthroscopy,2009,25(11):1224-1232.

[21] Freedman JA, Adamson GJ, Bui C, et al. Biomechanical evaluation of the acromioclavicular capsular ligaments and Reconstruction with an intramedullary free tissue graft. Am J Sports Med,2010,38(5):958-964.

[22] van Riet RP, Bell SN. Clinical evaluation of acromioclavicular joint pathology:sensitivity of a new test. J Shoulder Elbow Surg,2011,20(1):73-76.

[23] Tauber M, Koller H, Hitzl W, et al. Dynamic radiologic evaluation of horizontal instability in acute acromioclavicular joint dislocations. Am J Sports Med,2010,38(6):1188-1195.

[24] Rios CG, Arciero RA, Mazzocca AD. Anatomy of the clavicle and coracoid process for Reconstruction of the coracoclavicular ligaments. Am J Sports Med,2007,35(5):811-817.

[25] Scheibel M, Dr?schel S, Gerhardt C, et al. Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations. Am J Sports Med,2011,39(7):1507-1516.

[26] Motta P, Maderni A, Bruno L,et al.Suture rupture in acromioclavicular joint dislocations treated with flip buttons.Arthroscopy,2011,27(2):294-298.

[27] Boileau P, Old J, Gastaud O,et al.All-arthroscopic Weaver-Dunn-Chuinard procedure with double-button fixation for chronic acromioclavicular joint dislocation.Arthroscopy,2010,26(2):149-160.