Surgical management of multiple damages of superior shoulder suspensory complex disruptions with coracoid fracture

doi:10.21203/rs.3.rs-5002405/v1

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Surgical management of multiple damages of superior shoulder suspensory complex disruptions with coracoid fracture

https://doi.org/10.21203/rs.3.rs-5002405/v1

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Background

Multiple damages of the superior shoulder suspensory complex (SSSC) with coracoid fracture are exceedingly rare. Two or more site injuries of the SSSC frequently leads to delayed union, non-union and suffered motor dysfunction. Currently, the optimal surgical protocol has not been determined. This article reports our therapy approaches and clinical outcomes.

Methods

From January 2020 to June 2022. We treated 9 patients who had at least 3 injuries of SSSC and all with coracoid fracture. None of the patients had sustained concomitant injuries such as brachial plexus injury or rib fracture. All patients were treated with open reduction and internal fixation and coracoid fractures were reduced and fixed. The Visual Analgesia Score (VAS), American Shoulder and Elbow Surgeons (ASES) Score and Range of Motion (ROM) score were used to evaluation of postoperative recovery at the time of the last follow-up.

Conclusion

In conclusion, the manifestations of multiple SSSC disruptions with coracoid fracture are variable. A variety of surgical modalities for treating such injuries have been reported in the previous literature. In this article we introduce a novel, reliable surgical technique to treat such injuries.

In1993, the concept of SSSC was introduced by Goss which comprises a bony/soft tissue ring, including the glenoid process, the coracoid process, the coracoclavicular ligaments, the distal clavicle, the acromioclavicular joint, and the acromion.^[1] The integrity of SSSC is crucial for the biomechanical stability of the shoulder joint. Two sites or more injures can undermine the integrity of SSSC that may lead to complications such as delayed or non-union, diminished power, osteoarthritis.^[2] Isolated SSSC injuries occurred with relatively high frequency, two sites or more injures are relatively uncommon. Fractures of coracoid are rare and constitute only less than 2% of all fracture,^[3] so multiple damages of the superior shoulder suspensory complex with coracoid fracture is comparatively rare.

Currently, the optimal treatment for treating this type of damage remained controversial, some experts believed that we should take aggressive surgical management of such damages;whereas, others tend to choose conservative treatments. Besides, in cases where surgery is chosen, to fix one component of the disrupted structures or to restore all injuries is also controversial.^[4] But so far, not much literature exists about strategies for the treatment of such multiple disruptions, including the coracoid fracture, and there are few reports describing surgical methods,^[5] moreover the majority of these have not provided the assessment of functional outcomes at follow-up.

The purpose of the present report is to introduce our surgical and treatment strategy for multiple damages of superior shoulder suspensory complex disruptions with coracoid fracture and to describe the prognostic outcomes. Additionally, this paper provides a feasible and effective solution to treat such multiple disruption.

General Information

Patient inclusion criteria: (1) Multiple damages of unilateral SSSC involving coracoid fracture; (2) Patients are ≥ 18 and ≤ 60 years of age; (3) Normal shoulder function before the injury; (4) The patient is conscious and follows our treatment regimen.

Patient exclusion criteria: (1) Patients with vascular or nerve damage; (2)Patients are >60 or <18 years of age; (3) Patients with severe cardiopulmonary disease that cannot tolerate anesthesia; (4) Patients with preexisting shoulder joint mobility impairment.

Between January 2020 to June 2022, 9 patients with coracoid fracture with multiple damages of the superior shoulder suspensory complex were treated by our surgical protocol at our hospital, 7 patients were male and 2 patient were female. The mean age of the patients at surgery was 47.71 ± 8.71 years; 7 patients were left-sided and 2 patients were right-sided; 1 patient had a history of alcoholism and 2 of them had tobacco abuse; The mechanism of injury was traffic accident in 8 cases, falling from height in 1 cases. All of the patients fulfilled the inclusion and exclusion criteria and all cases underwent positive X-ray of shoulder and a lateral X-ray, CT to improve the examination before surgery. Ethical approval for this study was obtained from the Ethics Committee of our hospital. Informed consent was obtained from all patients and signed the informed consent form.

Surgical produce

This group of 7 cases of coracoid fracture with distal clavicle fracture and acromioclavicular joint dislocation and acromion fracture are, first of all, the posterolateral acromial approach incision was taken to expose the acromion fracture. After fracture reduction, the reconstruction locking plate was laid on the posterior part of the acromion and and fixed with screws. The shoulder transverse incision was then made along the distal clavicle, exposing the coracoid process, distal clavicle and acromioclavicular joint. The coracoid fracture was temporarily fixed with two guide Kirschner-wire (K-wire) after reduction. After satisfactory position was verified intraoperatively with C-arm fluoroscopy, two 4.0mm cannulated screws were affixed along the guide K-wires. Then the clavicle fracture was fixed with distal clavicular locking plate. Finally, bypass the suture from the basal aspect of the of coracoid process and protruded upward from the anterior and posterior border of clavicle respectively. The acromioclavicular joint was repositioned and fixed on the distal clavicular using the Nice knot.

There were 2 cases of coracoid fracture with acromioclavicular dislocation and acromial fracture. The surgical procedure of coracoid fracture and acromion fracture were the same as above. Then, 2.5mm bone channels were each drilled 2.5 cm and 3.5 cm distal to the distal clavicle and 1.5 cm anterior to the posterior border of the clavicle. After reduction and fluoroscopy to confirm the position is satisfactory, the acromioclavicular joint is fixed on the endobutton using the Nice knot.

Postoperative management

Postoperatively, the injured limb was immobilized with a broad arm sling two weeks. Since the second postoperative day, patients were encouraged to start moderate passive range of motion. The rehabilitation program was the similar for all patients, starting with 4 weeks of Codman exercises and passive shoulder range of motion exercises. This was followed by active range of motion exercises for two weeks. Partial resistance training was started 6 weeks postoperatively. Full range of motion in shoulder joint was allowed after 2 months.

Observation Indicators and Clinical Evaluation

The time between injury and surgery, the operation time, intraoperative blood loss, hospital stay time and the follow-up time were recorded. All patients were seen in follow up at 2 weeks, 1 month, 3 months, 6 months, and 12 months postoperatively and at least one time every year thereafter. The Visual Analgesia Score (VAS), American Shoulder and Elbow Surgeons (ASES) Score and Range of Motion (ROM) score was used to evaluate shoulder function before surgery and at the final follow-up.

Statistical analysis

All data were analyzed using IBM SPSS Statistics 25.0 statistical software for analysis. Parametric data, such as operative time, hospitalization day and blood loss, are described as mean ± standard deviation (SD). Proportional values were compared using χ2-analysis or Fisher exact test where applicable. A paired t-test was used to compare post-operative and pre-operative functional scores. Statistical significance level was set at p-value ≤ 0.05.

All patients were treated with our surgical protocol and performed by the same surgical team. The time from injury to surgery was 5.33 ± 2.00 days (range 3-9d); The operation time was 136.22 ± 24.51 min (range 105–188 min); intraoperative bleeding was 148.88 ± 54.18 ml (range 50–200 ml); The patient’s time in the hospital was 8.44 ± 1.59 days (range 7-11d) (Table 2).

Table 1

Patient demographics.
NO.of cases	Age(year)	Sex	Fracture site	Injury mechanism	History of tobacco and alcohol	Procedures
1	59	M	Right	Traffic accidents	Tobacc	Procedure 1
2	55	M	Left	Traffic accidents	No	Procedure 1
3	35	F	Left	Traffic accidents	Tobacc	Procedure 1
4	44	M	Left	Traffic accidents	No	Procedure 1
5	54	F	Left	Fall	No	Procedure 1
6	47	M	Left	Traffic accidents	No	Procedure 1
7	40	M	Left	Traffic accidents	No	Procedure 1
8	43	M	Right	Traffic accidents	No	Procedure 2
9	49	M	Left	Traffic accidents	Alcohol	Procedure 2
M = Male; F = Female; Procedure 1 = Coracoid fracture, acromion fracture, distal clavicle fracture open reduction and internal fixation. Acromioclavicular joint dislocation fixed by suture. Procedure 2 = Coracoid fracture and acromion fracture open reduction and internal fixation. Acromioclavicular joint dislocation fixed by endobutton.

Table 2

Operation related factors.
Related factors	Values (mean ± SD)
Time from injury to surgery (d)	5.33 ± 2.00
The operation time (min)	136.22 ± 24.51
Intraoperative bleeding (ml)	148.89 ± 58.18
Hospitalization days (d)	8.44 ± 1. 59
Follow-up time (month)	17.44 ± 2.00
SD = Standard deviation.

Table 3

Postoperative outcome of patients.
Evaluation items	Preoperative	2 weeks postoperatively	1 month postoperatively	3 months postoperatively	6 months postoperatively	12 months postoperatively	The last follow-up
VAS (mean ± SD)	5.78 ± 1.20	4.00 ± 1.00	3.56 ± 0.72	2.78 ± 0.44	1.89 ± 0.60	1.11 ± 0.60	0.78 ± 0.67^†
ASES (mean ± SD)	34.88 ± 6.69	45.00 ± 6.51	56.11 ± 7.18	66.22 ± 7.41	77.55 ± 7.50	83.77 ± 6.68	86.66 ± 3.90^†
Forward elevation (deg, mean ± SD)	33.66 ± 5.29	51.11 ± 8.46	72.88 ± 10.63	97.00 ± 12.99	120.22 ± 15.65	136.22 ± 15.16	157.55 ± 7.43^†
External rotation (deg, mean ± SD)	14.33 ± 2.59	17.88 ± 4.28	27.77 ± 4.14	35.11 ± 2.84	38.44 ± 2.55	39.55 ± 3.04	41.22 ± 2.16^†
Abduction (deg, mean ± SD)	49.44 ± 5.72	67.66 ± 6.44	76.66 ± 7.21	113.00 ± 8.54	133.66 ± 6.63	145.22 ± 7.20	155.11 ± 5.60^†
VAS = Visual Analogue Scale; deg = degrees; ASES = American Shoulder and Elbow surgeons score;
^†P-value < 0.05, the Parameters in different follow-up period after operation were compared with those preoperatively.

All the patients underwent clinical and radiographic assessments during the follow-up period. The mean follow-up time was 17.43 ± 2.00 months (range 14–20 months). No neurovascular complications, loosening or breaking of internal fixations, procedure-related death was observed in all cases. The clavicle and acromion internal fixators were removed in 6 patients before the last follow-up and the coracoid hollow screws were retained (Fig. 1).

The VAS was 5.78 ± 1.20 (range 4–8) before surgery, 4.00 ± 1.00 (range 3–6) at 2 weeks, 3.56 ± 0.72 (range 3–5) at 1 month, 2.78 ± 0.44 (range 2–3) at 3 months, 1.89 ± 0.60 (range 1–3) at 6 months, 1.11 ± 0.60 (range 0–2) at 12 months after surgery and 0.77 ± 0.67 (range 0–2)at the last follow-up. The mean preoperative pain VAS was significantly improved from 5.78 ± 1.20 (range 4–8) before surgery to 0.77 ± 0.67 (range 0–2) at the last follow-up (P < 0.05).

The ASES score was 34.88 ± 6.69 (range 27–47) before surgery, 45.00 ± 6.51 (range 39–57) at 2 weeks, 56.11 ± 7.18 (range 48–69) at 1 month, 66.22 ± 7.41 (range 55–80) at 3 months, 77.55 ± 7.50 (range61-86) at 6 months, 83.77 ± 6.68 (range 67–88) at 12 months after surgery and 86.66 ± 3.90 (range 77–89) at the last follow-up. The mean preoperative ASES was clearly improved from 34.88 ± 6.69 (range 27–47) before surgery to 86.66 ± 3.90 (range 77–89) at the last follow-up (P < 0.05).

The evaluation of shoulder motion includes four parts: internal rotation, external rotation, forward elevation, and abduction degrees. All of the range of motion (ROM) items achieved clear improvement compared with pre-operation. At the follow-up, the mean forward elevation, abduction degree and external rotation were improved from 36.66 ± 5.29 degrees (range 27–39);49.44 ± 5.72 degrees (range 40–57)༛14.33 ± 2.59 degrees (range 9–17) before the operation to 157.55 ± 7.43 degrees (range 140–165)༛155.11 ± 5.60 degrees (range 150–163)༛41.22 ± 2.16 degrees (range 38–44) at the last follow-up, respectively. The internal rotation increased from sacrococcygeal region preoperatively to T12 at the last follow-up.

The coracoid process is located in deep anatomical regions of the shoulder which provide attachment sites for many muscles and ligaments such as the short head of the biceps, coracobrachial, and pectoralis minor.^[5] It is usually hard to make a diagnosis of coracoid fracture based on physical findings alone and is experimentally very difficult to observe through routine anteroposterior radiograph of the shoulder.^{[5, 6]} Thus, coracoid fracture is frequently underdiagnosed. Therefore, a 3D computed tomography (3D-CT) or magnetic resonance imaging (MRI) examination is required when a fracture was suspected. Presently, many treatment methods have been reported in the literature for treatment coracoid fractures, such as Kirschner wires, cannulate screw and suture anchors.^[7] Fixation with a 4.5mm cannulated screw with washer is currently the mainstream treatment options for coracoid fracture.^{[5, 8]} Our new methods is to fix coracoid fracture with two 4.0mm cannulate screws. This method increases the fixation strength and rotational support, allowing our patients to begin passive ROM earlier.^[9]

In the previous literature reports, the most patients with distal clavicle fracture or acromioclavicular joint dislocation were treated with the clavicular hook plate.^[10–12] It offers a reliable method that is easy to apply with predominantly significant results; Additionally, the stress on the fracture site can be reduced by the hook of the clavicular hook plate. It allows early functional exercise and maintains acromioclavicular joint mobility.^{[10, 13, 14]} Despite that, it still has several shortcomings like subacromial impingement, rotator cuff damage, acromion fracture, hook cut-out and extraarticular ossification. Other than that, the hook plates need to be removed in a second operation after fracture consolidation.^[15–17] We describe a novel surgical protocol using distal clavicular locking plate in combination with the Nice-knot technique for the treatment of such injuries. The distal clavicle locking plate is neither exerted adverse effects on subacromial tissues nor increased the interference with the acromioclavicular joint and can provide a nice fixed effect.^[18] Moreover, the distal clavicle locking plate does not impose a load on the acromion and is therefore appropriate for patients with acromial fractures. Finally, we followed the suture along the coracoid base and up around the distal clavicle and locking plate and used the nice knot gradually tightened. The Nice knot is simple and does not loosen after tension, which is safer than the surgical knot and significantly reduce the risk of internal fixation failure of the distal clavicular internal fixation device.^{[19, 20]} Additionally, we adopted the modified loop plate combined with Nice-knot technique for the treatment of acromioclavicular joint dislocation for the patients with acromioclavicular joint dislocation not associated distal clavicle fractures. Our surgical approach has an advantage over other methods because it does not drill hole in the coracoid thus greatly avoiding the risk of iatrogenic coracoid fracture. Compared to patients treated with clavicular hook plates for acromioclavicular dislocation, our patients showed significant improvement in the range of motion of the shoulder abduction supination and forward flexion supination. Another important point is that this surgical procedure dose not a second surgery to remove the implant, reducing patient hospitalization costs and hospital length of stay.^{[21, 22]}

The optimal therapy regimen for multiple damages of the superior shoulder suspensory complex (SSSC) with coracoid fracture is still debatable. Although some scholars believe that good therapeutic effect can be achieved with conservative treatment of multiple damages of superior shoulder suspensory complex disruptions with coracoid fracture^[23–25]. However, there are a number of critical drawbacks in conservative methods, such as cosmetic complaints^[26], pain ^[24], malunion, fractures delayed union or no union, functional impairment and so on.^[5] Thus, an increasing number of literature research suggest that reconstruction of shoulder stability through surgery is a better treatment solution. Presently, the three following mainstream treatment options are included. The first surgical protocol is reduction and fixation of the acromion fracture, the distal clavicle fracture and the acromioclavicular joint dislocation and the coracoid fracture is treated conservatively. The case of 26 years old with triple damages of the SSSC was presented by Mariño et al. (2013). In this case the type II Neer fracture of the distal clavicle and the acromion fracture were treated with open reduction and internal fixation with Kirschner pins and cannulated screws, and a conservative treatment of the coracoid process fracture. At the end of follow-up, bone union was achieved in all fractures without nonunion or malunion, no recurrence of infection and he returned to his previous jobs.^[27] The second, the reduction and fixation of the coracoid fracture is tried under C-arm X-ray fluoroscopy. The dislocation of the acromioclavicular joint, the acromion fracture and the distal clavicle fracture then reduced by pulling the coracoacromial and coracoclavicular ligaments. Treatment was continued by open reduction and internal fixation until a satisfactory reduction was obtained if the fracture reduction of the was faulty. this operation method not only has the advantages of low surgical trauma,safe,less postoperative pain but also reduce the complications such as osteoarthritis of the acromioclavicular joint,acromioclavicular joint degeneration.^{[28, 29]} In 2012, Orthogona reported 1 cases treated with this surgery protocol. The follow-up data of functional scoring and subjective evaluation suggest a good prognosis but this literature does not provide detailed clinical information and imaging data. The third surgical protocol is reduction internal fixation of the coracoid fracture and other SSSC structures damages.^[30]

According to previous literature reports and the follow-up results of this group of patients, we believed that the third surgical protocol may be more desirable and meaningful. We treat patients with this surgical protocol and the prognosis for this patients is excellent. Although, this method also has several disadvantages such as long operation time, technical difficulty but this treatment schema can restore normal anatomical architecture of the shoulder joint and allow for functional exercise at early stage.it facilitates earlier rehabilitation exercises and promotes the recovery of shoulder joint function.

There were several limitations to our study. First, this is a retrospective clinical case analysis without control group.Second, the sample size was not large enough because multiple damages of the superior shoulder suspensory complex with coracoid fracture is a rare injury. Lastly, There were no overt osteoporosis patients in our sample, whether they would be suited for this procedure will require further clinical validation.

In conclusion, the manifestations of multiple SSSC disruptions with coracoid fracture are variable. Our patients have achieved favorable clinical outcomes demonstrates that operative treatment is an ideal solution to multiple SSSC disruptions with coracoid fracture. In this article we have introduced a novel, reliable surgical technique to treat such injuries.

Authors’ Contributions

YY and BW contributed to conception and design of the study. YY and BW contributed to methodology of the study. GS completed the data extraction. SH and ZW performed statistical analysis. GS wrote the first draft of the manuscript. GS and 0YY wrote sections of the manuscript. YY and BW reviewed and edited the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

Availability of data and materials

The datasets generated and analyzed during the present study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Shandong Provincial Hospital Affiliated to Shandong First Medical university. Patients were consented by an informed consent process that was reviewed by the Ethics Committee of Shandong Provincial Hospital Affiliated to Shandong First Medical university and certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki.

Consent for publication

All authors read the final manuscript and approved for publication.

Competing Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding Statement

This work was supported by the Study on the role and mechanism of autophagy-regulated NLRP3 inflammatory complex in the induction of periprosthetic osteolysis by VE-UHMWPE particles (Grant ZR2021MH301).

Acknowledgements

Not applicable.

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No competing interests reported.

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Surgical management of multiple damages of superior shoulder suspensory complex disruptions with coracoid fracture

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1. Introduction

2. Patients and methods

3. Results

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