Introduction

Post-traumatic disjunctions   are frequent in practice of sports such as Rugby, football, hockey, the bicycle, the rollerblading, the ski or surfing.  The organic mechanism most common is a fall with direct impact on the level of the shoulder, the arm in adduction.  According to the importance of the traumatism, the ligaments   (CC) and capsules it can be stretched, partially or completely broken.  Lesion severity is well reflected by the classification of , currently most used, which distinguishes six stages from increasing seriousness ( 1).

The ligaments (trapezoidal and ) are known as being “the ligaments hangers of the shoulder”, people responsible for stability in the vertical plan and the horizontal plane. Moreover, these ligaments are important in the physiology of the shoulder because they allow the synchronous rotation of the clavicle and the during the front elevation and of the abduction of the arm. 

In the event of severe disjunction   chronic (stages IV, V, VI), there exists a progressive resorption of these ligaments, making necessary the realization of a in the event of surgical treatment. The   some   technical proposed did not satisfy us, either because of their complexity, or because of their low mechanical resistance, source of failures. This led us to develop a technique, entirely carried out under , of effective and durable rebuilding of ligaments DC using an autograft . The aim of this item is to bring back this novel method as well as the preliminary results.

1: Classification of Disjunctions according to

Therapeutic indications

A survey of the US company of Sports medicine indicates that more than 80% of the questioned members prefer to discuss acute disjunctions in a preserving way. However the study of the literature shows that 20 to 40% patients forwarding an acute disjunction , discussed in a preserving way have nonsatisfactory results because of pains during the mobilization of the shoulder, of fatigability, lack of force, paraesthesias and/or esthetic embarrassment. This corroborates our clinical own experience.

Our indications are posed according to the classification of , by knowing that we never observed stage 6, exceptional.

Types I and II are discussed in a functional way and there is no indication to rebuild ligaments DC; in the event of persistent and resistant to treatment pains medical, a joint replacement   under is sufficient to relieve the patients.

Types IV, V and VI are discussed surgically. A simple reduction by Double-Button is sufficient in the acute forms. In the chronic forms, a trapezoidal ligament reconstruction and are necessary.

The indications in types III are discussed. It is initially advisable not to confuse a stage III (little moved) with a stage IV (with posterior displacement); for that, it is necessary to ask a radiography in profile to objectify posterior displacement. We propose an operative treatment in types III in the high level sportsmen especially if they practice a competitive sport and laborer.

The techniques with open sky being often balanced by plain cicatrices on the level of the shoulder, this led us to develop an entirely technique.

technique of Ligament reconstruction

Our operative procedure, entirely carried out under , consists in transferring in a cavity dug to the distal end from the clavicle, the ligament with a bone fragment taken at the expense of the former point of the (clerk's office bone-ligament-bone). It is about an amendment of the technique of (technical   ). A joining not with 4 beams, installed on two titanium platelets   (Double-Button, & ) maintains reduction DC and protects the transfer during the process of consolidation and cicatrization. The same joining is used to fix the fragment and the ligament in the clavicle (fig. 2).

The technique contains 6 stages:

1.   diagnoses and opening of the interval of the rotators to identify the basis of the .

2.   former (bone fragment of 5 X 5 X m) and taking away of the ligament (fig. 3).

3.   complete Exhibition of the basis of the and the higher face of the clavicle.

4.   distal Resection and cavitation of the clavicle (small box of 10 X 8 X m) (fig. 4).

5.   Reduction   and   fixing by the Double-Button (fig. 5).

6.   Transfer and fixing of the ligament AC with the bone fragment in the small box (fig. 6).

Into post-operative, the patients keep the arm in a splint bends with the body during 4 weeks before beginning rehabilitation with a kinesitherapist. However, as of the shortly after the intervention, the pendular one is authorized and the patients are encouraged to make use of their hand to eat, read, write, type with the computer.

Clinical experiment

Seven patients forwarding a disjunction severe and symptomatic ( Stage ) had   a   rebuilding   ligaments DC entirely under by this technique and were followed in a prospective way with radiographies and scanners of control. No clinical or radiological loss of reduction DC was observed ( 7). A patient forwarded a surface infection which cured without after-effect with local care and a . The score of Constant means was of 92 items 45 119]to the last retreat. All the patients resumed work in the nths following the operation and were very satisfied with the cosmetic result and the disappearance of the symptoms (pains   , fatigability of the arm, paraesthesias). All took again their initial sport, including the contact sport and to arm with the arm.

Biomechanical considerations

The operation of was criticized because of its low mechanical resistance: the resistance of the graft being only of 483N whereas the resistance of the ligaments trapezoidal and is of 815N. First of all, it should be noticed that all the biomechanical studies concerning the operation of were never made with the amendment made by . It appears obvious (at least surgically) that the bone fragment strengthens the fixing of the ligament in the clavicle.

Moreover, the reduction associated with the fixing provided by the Double-Button protects the graft during time from the osseous consolidation and the cicatrization .  The Double-button is consisted two titanium platelets (Endo-Short prop, & ) connected between them by a yarn of large diameter (PALLIATIVE CARE UNIT #5) not passed in quadruple beams (,     & ). The endon-short prop used usually in the reconstruction of the anterior cruciate ligament on the level of the knee showed a resistance of 1086N during the cyclic tests.  The resistance of the joining, as for it, is higher than 400N. The whole of the Double-Button + Fils in 4 beams thus constitutes, at least in theory, an assembly more solid than ligaments DC natives. In addition the titanium platelets prevent the joinings from “sawing” the clavicle or the . 

constitutes an assembly similar to our and contains a platelet with a button and a yarn . In a series using , it was brought back 50% of failures with secondary displacement . The authors allot this important failure rate to an abrasion of the joinings or an update of the nodes. We did not observe a failure in our experiment with the Double-Button. We think that is due to the favorable mechanical balance obtained by the Clerc's Office associated with the Double-Button. In addition, the joining is installed in lasso, which limits the update of the nodes.

Conclusions

This encouraging preliminary clinical experiment encourages us to proceed in this way.

In disjunctions AC severe and symptomatic chronicles, this technique is employed in routine in the service.  This technique, in spite of its minicomputer-invasive nature, allows an quasi-anatomical repair of ligaments DC thanks to the use of a Clerc's Office biological and vascularized associated with a solid fixing. The bone fragment has the double advantage of facilitating and of strengthening the fixing of the ligament in the clavicle. Fixing by the Double-Button remains despite everything flexible device, making it possible to preserve the physiological movements of rotation of the clavicle and the during the front elevation-abduction or rotation of the arm, which is capital for the resumption of the sports of launching.

The realization of this technique entirely under allows a precision of the operational gestures (because of optical enlarging) and a reduced morbidity appreciated by the patients of which part of the motivation to request a surgical cure is often the esthetic embarrassment. The other advantages are that no ablation of hardware is necessary and that the intervention can be realized into ambulatory.

In the cases of acute disjunctions (in the first 3 weeks) and severe (stages 4 and 5 of and certain stages 3, at the sporting or laborer subjects), we carry out a reduction and a fixing isolated by Double-Button under or radioscopy. The very short distance (3 to m) associated with the fact that the area is very richly vascularized makes it possible to obtain an anatomical and durable cicatrization ligaments trapezoidal and by simple reduction thanks to the Double-Button (fig. 7). Our clinical experiment showed us that   in   the   acute disjunctions, the Clerc's Office was not necessary.