Superior Shoulder Suspensory Complex (SSSC) is a bone and soft-tissue ring securing the connection of the upper extremity to the axial skeleton via the clavicle and sternoclavicular joint. An isolated injury to one component of SSSC is usually stable. An injury to 2 of its components is a potential source of shoulder girdle instability and requires surgical stabilisation. An injury affecting 3 and more components is extremely rare and surgical stabilisation should be indicated. Our study presents the case of a 50-year-old man who fell off the bicycle and sustained a direct blow to his left shoulder resulting in an ipsilateral fracture of the coracoid and acromion process combined with the fracture of the distal end of the clavicle. Following a standard clinical examination and a subsequent X-ray and a CT scan with three-dimensional shoulder reconstruction, an open reduction and stabilisation of all the injured SSSC components was performed. Later, early and gradual rehabilitation of the shoulder girdle was commenced. At 48 weeks after the surgery, almost full range of motion of the shoulder joint was achieved and the muscle strength of the operated upper extremity was comparable to that of the healthy one. Key words:Superior Shoulder Suspensory Complex, fracture, acromion, coracoid process, clavicle.

• MeSH
• akromion diagnostické zobrazování   zranění   MeSH
• fraktury kostí diagnostické zobrazování   rehabilitace   chirurgie   MeSH
• klíční kost diagnostické zobrazování   zranění   MeSH
• lidé středního věku MeSH
• lidé MeSH
• lopatka diagnostické zobrazování   zranění   MeSH
• poranění ramene diagnostické zobrazování   rehabilitace   chirurgie   MeSH
• processus coracoideus diagnostické zobrazování   zranění   MeSH
• vnitřní fixace fraktury MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH

PURPOSE: Until now, classifications of coracoid fractures have been based on plain radiographs, without use of 3D CT reconstructions. Therefore, the aim of the present study has been to describe the pathoanatomy of these fractures and their associated injuries to the shoulder girdle, on the basis of 3D CT reconstructions. METHODS: The cohort comprised 39 patients, who each sustained a coracoid fracture investigated with 3D CT reconstructions. The patients were assessed in terms of age, gender, pathoanatomy of the coracoid fracture, fractures of other parts of the scapula, and associated injuries to the shoulder girdle. RESULTS: We identified 24 fractures of the base, one fracture of the beak body, eight fractures of the apex, and six comminuted fractures of the coracoid process. A total of 22 associated injuries were found (7 fractures of the acromion, 5 fractures of the anterior glenoid rim, 3 fractures of the superior glenoid, 1 fracture of the inferior glenoid, 4 fractures of the surgical neck, 2 fractures of the scapular body) and 18 other associated injuries to the shoulder girdle (8 AC dislocations, 5 proximal humeral fractures, and 5 clavicular fractures). CONCLUSION: On the basis of 3D CT reconstructions, four basic coracoid fracture patterns were identified. The authors´ findings and literature review have shown that a considerable number of coracoid fractures are combined with injuries to other parts of scapula and shoulder girdle. These associated injuries must be taken into account and targeted when taking the patient's history, and during clinical and primarily radiological examinations.

• MeSH
• akromion MeSH
• fraktury kostí * diagnostické zobrazování   epidemiologie   MeSH
• klíční kost MeSH
• lidé MeSH
• lopatka diagnostické zobrazování   MeSH
• počítačová rentgenová tomografie MeSH
• processus coracoideus * MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH

PURPOSE OF THE STUDY: This study investigated the relationship between the position of the tip of the coracoid process (CP) relative to the glenoid with subscapularis (Ssc) tears. We hypothesized that the coracoid tip is more inferior, lateral and posterior in patients with Ssc tear. MATERIAL AND METHODS: This research enrolled 34 isolated Ssc tears and 44 controls. We introduced the axial central glenoid-coracoid angle (acGCA) and sagittal central glenoid-coracoid angle (scGCA) to evaluate the position of the tip of the CP relative to the glenoid center on MRI images. In both groups, acGCA, scGCA on MRI and critical shoulder angle (CSA), glenoid inclination (GI) on true anterior-posterior shoulder radiography were evaluated. RESULTS: When both groups were compared in terms of acGCA, the acGCA values of the Ssc tear group were significantly higher than the control group (p<0.001). The best cut-off value of acGCA for Ssc tears was 28.3°. acGCA values higher than 28.3° showed 93.3% sensitivity and 93.1% specificity for Ssc tears (likelihood ratio:13.53, AUC: 0.979, 95% CI of AUC: 0.950- 0.999). In terms of acGCA, the power analysis between Ssc tears group and control group was 99.9% between Ssc tears and the control group (effect size d=2.63). When both groups were compared in terms of scGCA, the scGCA values of the Ssc tear group were significantly higher than the control group (p<0.001). The best cut-off value of scGCA for Ssc tears was 41.4°. Scores of scGCA greater than 41.8° showed 80% sensitivity and 89.7% specificity for Ssc tears (likelihood ratio: 7.73, AUC: 0.899 95% CI of AUC: 0.837-0.958). In terms of scGCA, the power analysis between Ssc tear and control group was 99.8% (effect size d=1.23). When both groups were compared in terms of CSA and GI; CSA and GI values in the Ssc tear group were significantly higher (p<0.001 and p<0.012, respectively). CONCLUSIONS: AcGCA values higher than 28.3° indicate that the coracoid tip is located more laterally and posteriorly; scGCA values higher than 41.8° indicate that the coracoid tip is located more inferiorly and these two new indexes are showing that more laterally, posteriorly and inferiorly coracoid tip is related to subscapularis tears. KEY WORDS: coracoid process, subscapularis tear, coracoid morphology, scapula morphology.

• MeSH
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• magnetická rezonanční tomografie * metody   MeSH
• poranění rotátorové manžety * diagnostické zobrazování   MeSH
• processus coracoideus * zranění   diagnostické zobrazování   MeSH
• ramenní kloub diagnostické zobrazování   MeSH
• senzitivita a specificita MeSH
• studie případů a kontrol MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

Glenohumeral joint is the most frequently dislocated joint of the human body. Concomitant fractures of the coracoid process and tuberculum majus in humeral dislocation of the shoulder joint are rarely described. Concomitant fractures are results of a significant contraction of the surrounding muscles and rotator cuff during a cerebral paroxysm. Due to the small number of cases, the treatment of such injuries is not simple and it is based on an algorithm for treatment of isolated injuries of these anatomical structures. In this case report, we describe a concomitant fracture of the coracoid process and tuberculum majus during an anterior shoulder dislocation in 25-year-old patient after an epileptic seizure. The injury was treated in our department surgically, with a good functional result. The absolute Constant score for the operated arm is 95 points, the relative Constant score is 97%, DASH score 0, VAS score 0.

• MeSH
• dospělí MeSH
• fraktury kostí * komplikace   MeSH
• humerus MeSH
• lidé MeSH
• luxace ramenního kloubu * komplikace   chirurgie   MeSH
• processus coracoideus MeSH
• ramenní kloub * MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH

• MeSH
• akromion chirurgie   MeSH
• artroskopie metody   využití   MeSH
• chirurgická dekomprese metody   využití   MeSH
• dospělí MeSH
• lidé MeSH
• syndrom zhmožděného ramene diagnóza   chirurgie   MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• srovnávací studie MeSH

Almost 70 scapular fractures in children and adolescents, up to the age of 17 years, have been described in detail in the literature since 1839. The diagnosis of these injuries was based on autopsy, radiographs, CT and MRI examinations. The most frequent findings were fractures/epiphyseolyses of the coracoid, followed by fractures of the infraspinous part of the body and avulsion of the inferior angle of the scapular body. Less common were fractures of the acromion. Intra-articular fractures of the glenoid, or separation of an intact glenoid along the line of the anatomical or surgical necks, were reported only sporadically. Scapulothoracic dissociation was also recorded in several cases. The majority of fractures were treated non-operatively; operative treatment was used in glenoid fractures, certain fractures of the coracoid and fractures of the scapular body with intrathoracic penetration. Except for scapulothoracic dissociation, outcomes of treatment of these injuries were very good.

• MeSH
• akromion MeSH
• dítě MeSH
• fraktury kostí * diagnostické zobrazování   chirurgie   MeSH
• fraktury proximálního humeru * diagnostické zobrazování   MeSH
• intraartikulární fraktury * MeSH
• lidé MeSH
• lopatka chirurgie   MeSH
• mladiství MeSH
• poranění hrudníku * MeSH
• radiografie MeSH
• Check Tag
• dítě MeSH
• lidé MeSH
• mladiství MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

• MeSH
• akromioklavikulární kloub chirurgie   patologie   MeSH
• akromion chirurgie   MeSH
• artroskopie metody   MeSH
• chirurgická dekomprese metody   MeSH
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• spokojenost pacientů MeSH
• syndrom zhmožděného ramene chirurgie   MeSH
• výsledek terapie MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• přehledy MeSH

»: Fractures of the growing scapula account for about 0.1% of all pediatric fractures, with the majority occurring at an age of ≥10 years. »: Radiographic diagnosis requires a detailed knowledge of the ossification sequence of the growing scapula. Computed tomography examination is indicated for displaced fractures of the glenoid fossa, the scapular neck, and complex fractures; magnetic resonance imaging should be performed in cases of suspected injury to the physis and with stress fractures, depending on patient age and the potential need for general anesthesia during the scanning process. »: Separation of the base of the coracoid process is often associated with acromioclavicular dislocation. Clavicular fractures rarely occur in combination with injuries to the growing scapula. »: The majority of scapular fractures can be treated nonoperatively. Indications for surgery are displaced intra-articular fractures, scapular neck fractures with a displacement of >2 cm, coracoid base separation associated with acromioclavicular dislocation, and scapulothoracic dissociation. »: Displaced intra-articular fractures of the glenoid fossa should be followed after healing until skeletal maturity. Complications are rare and occur most frequently with scapulothoracic dissociation.

• MeSH
• dítě MeSH
• fraktury proximálního humeru * MeSH
• klíční kost diagnostické zobrazování   zranění   MeSH
• kloubní jamka lopatky * MeSH
• lidé MeSH
• lopatka chirurgie   MeSH
• mladiství MeSH
• vnitřní fixace fraktury MeSH
• Check Tag
• dítě MeSH
• lidé MeSH
• mladiství MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

Téma: Práce se zabývá řešením nestability akromioklavikulárního (AC) kloubu novou mininvazivní metodou Zip Tight, která nahrazuje otevřené operace korakoklavikulárních vazů [1, 8, 13, 15]. Materiál a metoda: Od 1. 3. 2012 do 30. 8. 2013 jsme na našem oddělení ošetřili 26 pacientů s diagnózou AC dysjunkce. Z toho bylo osm pacientů léčeno konzervativně, 16 pacientů bylo primárně indikováno k OP stabilizaci Zip Loop technikou a dva pacienti byli indikováni k operaci odloženě. V komparativním souboru od 1. 11. 2011 do 28. 2. 2012, jsme ošetřili 21 pacientů s diagnózou AC dysjunkce. Z toho pět pacientů bylo léčeno konzervativně a 16 pacientů bylo primárně indikováno k OP stabilizaci klasickou technikou (revize a sutura CC vazu [1], transfixace 2x Ki drátem a kličkou). Výsledky: Všech 18 operovaných pacientů se vrátilo k předúrazovým sportovním aktivitám za 12,5 týdne po úrazu. Při ambulantních rentgenologický kontrolách jsme zaznamenali u třech pacientů (17 %) sekundární ztrátu repozice. U dvou došlo k vycestování distální jistící kotvy z korakoidu, u jednoho pacinta jsme zaznamenali patologickou zlomeninu klíční kosti, mezi dvěma odfrézovanými kanály. Druhý kanál bylo nutno odfrézovat z důvodu špatně zacíleného původního kanálu. Hluboký infekt jsme nezaznamenali. Ve srovnávacím souboru 16 operovaných pacientů se vrátilo k předúrazovým sportovním aktivitám bez omezení ramenního kloubu, za 14 týdnů po úrazu. Při ambulantních kontrolách jsme nepozorovali ztrátu repozice. Zaznamenali jsme u tří pacientů infekt rány, který byl dohojen po extrakci kovů. Diskuze: Do diskuze jistě připadá otázka revize AC skloubení a intraartikularního disku [3], který je u akutních AC dysjunkcí poškozen. U klasické operace jsme diskus extirpovali a reponovali klíční kost k akromiu. Novou metodou reponujeme klíční kost zavřeně a AC kloub nerevidujeme. Při snadné repozici klíčku do AC kloubu nedochází k tlaku na akromion a jeho lateralizaci. Nelze-li takto před operací reponovat AC kloub do anatomického postavení [15], k čemuž dochází většinou při chronické instabilitě, pak je revize AC skloubení peroperačně nutná. Další otázkou je cena implantátu ve srovnání s klasickou operací, tedy použitím dvou Kirschnerových drátů a jedné drátěné kličky. Cena samotného implantátu je samozřejmě několikanásobně vyšší, ale náklady na léčení jsou celkově nižší, odpadá nutnost následného operačního zákroku a hospitalizace pro odstranění OS materiálu. Dále je snížen počet ambulantních kontrol, a tím je tedy zkrácena doba rehabilitace, a tím i léčba. Návrat pacienta do práce a ke sportovním aktivitám je proto rychlejší. Nevýhodami samozřejmě jsou: RTG zátěž při operačním výkonu, které nebylo při klasické OP potřeba, technicky obtížnější kontrola uložení kotvy pod procesus coracoideus - nutno RTG a palpační kontroly, u nás nepoužíváme artroskopickou [6, 8, 9] kontrolu. Závěr: Stabilizace AC dysjunkce pomocí Zip loop implantátu je méně invazivní metoda ve srovnání s jinými operačními metodami. Výsledky repozice a obnovení kongruence AC kloubu Zip Loop technikou jsou srovnatelné s výsledky získanými otevřenou technikou repozice.Přináší možnost časnějšího návratu k dením aktivitám, odpadá nutnost následné operace k odstranění osteosyntetického materiálu. Nevýhodou zůstává radiační zátěž při operaci.

Purpose of the study: To present the ZipTight (Biomet, Inc.) technique and its results in the stabilization of acromioclavicular joint dislocation performed out at our department. Material and methods: From 1. 3. 2012 to 30. 8. 2013, we provided care for 26 patients with the diagnosis of AC joint dislocation (Group I). Acute surgical stabilization was performed in 16 patients, secondary surgery was performed in 2 patients (one for late diagnosis, one for additional injuries). Eight patients were treated conservatively. Patients with Tossy type III and coracoclavicular dissociation more than 10mm were indicated for surgery. In the surgically treated group there were 14 male and 4 female pa-
tients, with an average age of 33.8 years. In the comparative patient group (Group II) from 1. 11. 2011 to 28. 2. 2012, there were 21 patients treated for AC-joint dislocation. Acute surgery (joint stabilization with 2 K-wires + steel wire loop) was performed in 16 patients, secondary surgery was not performed. Five patients were treated conservatively. Results: All 18 patients of Group I returned to their pre-operative activities without any problems or pain within 12.5 weeks after surgery. Radiographic evidence of loss of reduction, with no effect on the clinical outcome, was recorded in 3 patients (17%) during post-operative controls on 3rd, 6th and 12th week after surgery. In two patients, post-operative pull-out of the implant from the coracoid was seen, one patient sustained pathological fracture of clavicle in between two drill holes, when a second canal was needed because of malposition of the first canal. We did not observe any cases of deep wound infection. In Group II all 16 patiens returned to their pre-operative activities without complaints or pain within 14 weeks post surgery. We did not observe radiographic evidence of loss of reduction. We noticed 3 patients with wound infection, all healed after the implant removal. Discussion: The revision of AC-joint and revision of the injured disc can/should be discussed. At classical open surgery we performed joint revision with excision of the damaged disc and reduced the lateral end of the clavicle to the acromion. In the new method we do closed reduction, without AC-joint revision. The degree of AC-joint injury could be examined manually before operation: if the clavicle could be easily reduced in the AC-joint, than the joint revision is not necessary; if reduction is not possible, than the joint revision is indicated. This is usually the case in injuries older, than 4weeks. Another question is the price of the implant, which is doubtlessly higher than that of 2 K-wires and a steel wire loop, but the cost of treatment is lower: there is no need of second surgery for implant removal. Also the number of ambulatory controls is lower and, due to shorter rehabilitation, recovery and return to sports activities is earlier. Disadvantage is the need to use image intensifier, which was not the case during classic surgery. Anchoring of distal component is more demanding on surgeons skills. Conclusions: Stabilization of AC-joint dislocation with Zip Loop implant is a less invasive procedure leading to restoration of the coracoclavicular ligament complex with dynamic stability. In comparison with open procedures, it allows the patients to return earlier to daily activities and eliminates the necessity of secondary operation for implant removal. The loss of full reduction in three cases, as observed on radiographs during the controls, was not accompanied by any clinical problems and is in concordance with the findings of other authors.

• Klíčová slova
• Zip Tight technika, RTG asistovaná metoda,
• MeSH
• akromioklavikulární kloub * chirurgie   patofyziologie   zranění   MeSH
• diagnostické techniky a postupy * MeSH
• kostní dráty využití   MeSH
• lidé MeSH
• miniinvazivní chirurgické výkony * metody   využití   MeSH
• ortopedické výkony metody   využití   MeSH
• pooperační péče MeSH
• retrospektivní studie MeSH
• sportovní úrazy chirurgie   rehabilitace   terapie   MeSH
• statistika jako téma MeSH
• výsledky a postupy - zhodnocení (zdravotní péče) MeSH
• Check Tag
• lidé MeSH

PURPOSE OF THE STUDY: To present the TightRope (Arthrex, Naples, FL) technique and its results in the arthroscopic stabilisation of acute acromioclavicular joint (ACJ) dislocation carried out at our department. MATERIAL AND METHODS: From July 2009 till December 2010, arthroscopic stabilisation of acute ACJ dislocation was performed in 22 patients. The group consisted of 18 men and four women with an average age of 37.4 years. The Rockwood type III to type V ACJ dislocations (III, 16; IV, 1; V, 5) were indicated for surgery. The average interval between injury and surgery was 5.4 days. In all cases, a second-generation TightRope implant was inserted by the EndoButton technique joining the distal end of the clavicle and the coracoid process. The results were evaluated using the UCLA Shoulder Scale at 6 months after surgery. RESULTS: All 22 patients returned to their pre-operative activities without any restriction of shoulder motion within 5 months of surgery. The average post-operative UCLA score was 31.2 points (range, 28 to 35). Radiographic evidence of the loss of full reduction, with no effect on the clinical outcome, was recorded in four patients (18%) during post-operative rehabilitation. Of these, one had Rockwood type III, two had type IV and one had type V dislocations. One patient suffered post-operative pull-out of the implant from the coracoid; three patients showed skin wound healing by second intention above the lateral clavicle, with one requiring surgical repair under local anaesthesia. There was no neurovascular complication, intra- or postoperative fracture of the coracoid process or lateral clavicle, or deep wound infection. DISCUSSION: Arthroscopic stabilisation of acute ACJ dislocation is a minimally invasive procedure providing the coracoclavicular ligament complex with dynamic stability. In comparison with open procedures, it is less painful post-operatively, allows the patients to return early to daily activities and has a better cosmetic effect. It eliminates the necessity of removing the osteosynthetic material, as is the case in commonly used techniques such as Bosworth's method, K-wiring, osteorrhaphy or hook plate insertion. The loss of full reduction in four patients, as observed on radiographs during their rehabilitation, was not accompanied by any clinical problems and is in agreement with the findings of other authors. In our group, it occurred in Rockwood grade IV and grade V dislocations. For these, there is a possibility of using two implants in order to increase stability and prevent the loss of full reduction but this involves a higher risk of coracoid fracture, extension of operative time and higher costs. However, a loss of reduction in some patients has also been reported by the authors who have used two implants. Therefore we prefer using a single TightRope implant, particularly in acute grade III ACJ dislocations requiring surgical treatment in patients engaged in repetitive overhead activities related to sports or occupation. CONCLUSIONS: Arthroscopic stabilisation of acute ACJ dislocations using a single TightRope implant is an elegant minimally invasive method with good results in indicated cases. It proves efficient particularly in Rockwood type III injuries in patients who have to do repetitive overhead activities. Acute type IV and type V ACJ dislocations treated by this technique show a loss of full reduction on radiographs more frequently, although no effect on the clinical outcome is evident.

• MeSH
• akromioklavikulární kloub zranění   patofyziologie   radiografie   MeSH
• artroskopie * škodlivé účinky   přístrojové vybavení   metody   MeSH
• čas zasáhnout při rozvinutí nemoci MeSH
• dospělí MeSH
• interní fixátory MeSH
• lidé MeSH
• luxace ramenního kloubu diagnóza   patofyziologie   chirurgie   MeSH
• obnova funkce MeSH
• pooperační komplikace diagnóza   MeSH
• pooperační období MeSH
• retence protézy škodlivé účinky   metody   MeSH
• retrospektivní studie MeSH
• rozsah kloubních pohybů MeSH
• selhání protézy etiologie   MeSH
• výsledek terapie MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• anglický abstrakt MeSH
• časopisecké články MeSH