Recurrent Anterior Shoulder Dislocation After Trauma with Coracoid Apophysis Fracture - A Rare Association / Luxação anterior recorrente do ombro após traumatismo com fratura apófise coracoide - Uma associação rara

Abstract Anterior dislocations represent about 96% of total shoulder dislocations, with recurrence/instability being more common in young patients. Injury of other shoulder structures is frequent, namely bony Bankart lesion. However, the association with coracoid apophysis fracture is very rare. The present article describes the clinical case of a 67-year-old man who presented to the emergency department with complaints of persistent omalgia, with acute episodes, beginning after a fall from his own height. The patient also presented history of shoulder trauma 3 months earlier, which was evaluated at another hospital. Shoulder anterior dislocation was observed radiographically, and the computed tomography (CT) confirmed bone erosion of the anteroinferior part of the glenoid (bone loss of about 50% of the anteroposterior diameter in the lower region of the glenoid), with almost complete resorption of the bony Bankart lesion (apparent in later analysis of the radiography of the initial traumatic episode). Connectedly, a transverse fracture of the coracoid apophysis (type II in the Ogawa classification) was diagnosed. The patient was submitted to surgical treatment, with anterior bone stop confection using the remnant of the fractured fragment of the coracoid supplemented by tricortical autologous iliac graft, fixed with cannulated screws (according to the Bristow-Latarjet and Eden-Hybinett techniques). In the postoperative follow-up, a good functional result was observed, with no new episodes of dislocation and no significant pain complaints. A rare association of shoulder lesions is described, and the challenge of their treatment is highlighted, given the late diagnosis, as in the case presented.

Resumo As luxações anteriores representam cerca de 96% do total de luxações do ombro, sendo a recidiva/instabilidade mais comum em pacientes jovens. A lesão de outras estruturas do ombro é frequente, nomeadamente a lesão óssea de Bankart. Contudo, a associação com a fratura da apófise coracoide é muito rara. Este artigo descreve o caso clínico de um homem de 67 anos que recorreu ao serviço de urgência com queixas de omalgia persistente, com episódios de agudização, iniciados após queda da própria altura. O paciente apresentava ainda histórico de trauma do ombro 3 meses antes, avaliado em outro hospital. A luxação anterior do ombro foi constatada radiograficamente, e a tomografia computorizada (TC) do ombro confirmou erosão óssea da vertente anteroinferior da glenoide (perda óssea de cerca de 50% do diâmetro anteroposterior na região inferior da glenoide), com reabsorção quase completa de lesão óssea de Bankart (aparente em análise a posteriori da radiografia do episódio traumático inicial). Associadamente, foi diagnosticada uma fratura transversa da apófise coracoide (tipo II da classificação de Ogawa). O paciente foi submetido ao tratamento cirúrgico, com confecção do batente ósseo anterior utilizando remanescente do fragmento fraturado do coracoide suplementado por enxerto autólogo tricortical do ilíaco, fixados com parafusos canulados (de acordo com as técnicas de Bristow-Latarjet e Eden-Hybinett). No seguimento pós-operatório, foi observado um bom resultado funcional, sem novos episódios de luxação e sem queixas álgicas significativas. Descreve-se uma associação rara de lesões do ombro, e salienta-se o desafio do tratamento das mesmas dado o seu diagnóstico tardio, como no caso apresentado.

Pinzamiento subcoracoideo: diagnóstico e inyección guiada por ecografía en atletas lanzadores / Subcoracoid impingement. Diagnosis and ultrasound-guided injection in throwing athletes

El pinzamiento subcoracoideo es un cuadro poco frecuente y, por lo tanto, su diagnóstico plantea un reto al cirujano ortopédico. Se manifiesta con un dolor sordo en la región subcoracoidea y dolor a la palpación en el proceso coracoideo, como resultado del pinzamiento del músculo subescapular entre el proceso coracoideo y el troquín del húmero. El objetivo de esta nota técnica es describir una alternativa diagnóstica y la inyección guiada por ecografía para atletas lanzadores con pinzamiento subcoracoideo. Nivel de Evidencia: IV

Subcoracoid impingement is a rare condition, therefore, its diagnosis poses a challenge to the orthopedic surgeon. It manifests with dull pain in the subcoracoid region and pain on palpation in the coracoid process as a result of impingement of the subscapularis muscle between the coracoid process and the lesser tubercle of the humerus. The objective of this technical note is to describe an alternative diagnosis and ultrasound-guided injection for throwing athletes with subcoracoid impingement. Level of Evidence: IV

Risk Factors for Coracoid Graft Osteolysis after the Open Latarjet Procedure / Fatores de risco para osteólise do enxerto do coracoide após o procedimento de Latarjet aberto

Abstract Objective Coracoid osteolysis has been described as a possible complication after the Latarjet procedure. The aim of the present study was to investigate the incidence and risk factors associated to coracoid graft osteolysis and to correlate them with clinical results. Methods A retrospective review of 38 Latarjet procedures was conducted. Computed tomography (CT) scans were obtained from all of the patients before and at least 1 year after the surgery. Coracoid osteolysis was evaluated and correlated to preoperative factors, namely: age, smoking status, and preoperative glenoid bone loss. The patients were divided into 2 groups: A (no or minor bone resorption) and B (major or total bone resorption). The functional outcome was determined by the Rowe score. Results Coracoid graft osteolysis occurred in 22 cases (57.8%). The mean preoperative glenoid defect was 22.8% in group A, and 13.4% in group B (p= 0.0075). The mean ages of the subjects in both groups were not significantly different. Smoking did not seem to affect the main outcome either, and no correlation was found between graft osteolysis and postoperative range of motion, pain, or Rowe score. There were no cases of recurrent dislocations in our sample, although four patients presented with a positive anterior apprehension sign. Conclusion Bone resorption of the coracoid graft is present in at least 50% of the patients submitted to the Latarjet procedure, and the absence of significant preoperative glenoid bone loss showed to be the only risk factor associated with severe graft osteolysis, even though this did not influence significantly the clinical outcome.

Resumo Objetivo Osteólise do processo coracoide é descrita como uma possível complicação da cirurgia de Latarjet. O objetivo do presente estudo foi avaliar a incidência e fatores de risco associados à osteólise do enxerto do coracoide e correlacioná-los com resultados clínicos. Métodos Foi realizada uma revisão retrospectiva incluindo 38 casos submetidos ao procedimento de Latarjet. Em todos os casos, foi realizada uma tomografia computadorizada antes e pelo menos 1 ano após a cirurgia. A presença de osteólise do coracoide foi avaliada e correlacionada com os seguintes fatores de risco: idade, tabagismo, e perda óssea pré-operatória da glenóide. Os pacientes foram divididos em dois grupos: A (ausência ou menor reabsorção óssea) e B (maior reabsorção óssea ou total). A avaliação funcional foi determinada através do escore de Rowe. Resultado Osteólise do processo coracoide ocorreu em 22 casos (57,8%). O defeito ósseo médio pré-operatório da glenóide foi de 22,8% no grupo A e de 13,4% no grupo B (p= 0.0075). A média de idade dos casos em ambos os grupos não apresentou diferença estatística. Tabagismo também não esteve relacionado com diferenças no resultado. Não houve correlação entre a presença de osteólise e o arco de movimento, dor ou ao escore de Rowe. Não houve casos de reluxação; entretanto, quatro pacientes apresentaram apreensão anterior no exame físico. Conclusão A reabsorção do processo coracoide ocorreu em pelo menos 50% dos pacientes submetidos à cirurgia de Latarjet, e a ausência pré-operatória de perda óssea significativa da glenóide foi o único fator de risco associado a osteólise mais severa do enxerto, porém sem influência no resultado clínico.

The axillary arch inserted to the coracoid process compressing the brachial plexus / El arco axilar insertado en el proceso coracoideo comprimiendo el plexo braquial

The axillary arch is a variant slip extending between the latissimus dorsi muscle and the pectoralis major. During educational dissection, a variant muscle was found in left arm of 70-year-old female cadaver. A slip muscle originated from the lateral margin of the latissimus dorsi and crossed the axilla obliquely. Therefore, we defined this muscular variation as axillary arch. It ran anterior (superficial) to the medial and lateral cords of the brachial plexus, and then it inserted to coracoid process. We reported this variant muscle and discussed its clinical significances.

El arco axilar es una variante que se extiende entre el músculo dorsal ancho y el pectoral mayor. Durante la disección educativa, se encontró una variante muscular en el brazo izquierdo de un cadáver de una mujer de 70 años. El músculo deslizante se originó en el borde lateral del dorsal ancho y cruzó la axila oblicuamente. Por lo tanto, definimos esta variación muscular como el arco axilar. Se extendió anterior (superficial) a los cordones medial y lateral del plexo braquial, y luego se insertó en el proceso coracoideo. Reportamos esta variante muscular y discutimos sus significados clínicas.

Treatment of dislocation of acromioclavicular joint with TightRope fixation through a small incision in the base of coracoid process / 中国骨伤

OBJECTIVE@#To explore the method and effect of small incision TightRope fixation in the treatment of fresh acromioclavicular joint dislocation.@*METHODS@#From January 2016 to May 2018, 28 cases of fresh acromioclavicular dislocation were treated, including 20 males and 8 females, aged 26 to 87 years with an average age of 51.3 years. The modified Rockwood classification included 1 case of typeⅡ, 22 cases of typeⅢand 4 cases of type V. The average time from injury to operation was 2.4 days. The operative time, shoulder function recovery time and postoperative complications were recorded, and the immediate reduction effect and Karlsson function of shoulder joint were evaluated.@*RESULTS@#In 28 patients, only one Rockwood typeⅡ was used to reconstruct the pyramidal ligament, and the other 27 were used to reconstruct the pyramidal ligament and the trapezoid ligament. The average operation time was (66.50±12.62) min (including intraoperative fluoroscopy time). Twenty-eight cases were followed up for 11 to 20 (16.7±4.6) months. The recovery time of shoulder function was 2 to 7 months with an average of 4 months. During the follow-up period, 1 case had osteolysis and loss of reduction at the clavicular plate site, and the rest had no complications such as re-dislocation and button plate prolapse. Immediate reduction effect after operation:6 cases with reduction insufficiency, 17 cases with complete reduction and 5 cases with excessive reduction;Karlsson function evaluation of shoulder joint in the last follow-up:excellent in 21 cases, good in 6 cases and poor in 1 case;Pearson analysis =0.060, suggesting that the immediate reduction effect of fresh acromioclavicular dislocation operation has no significant correlation with Karlsson function evaluationof shoulder joint in the last follow-up.@*CONCLUSION@#TightRope fixation through a small incision in the base of coracoid process is a simple and effective method for the treatment of dislocation of acromioclavicular joint. There was no significant correlation between the slight difference of immediate reduction effect within 5 mm and Karlsson function evaluation of shoulder joint in the last follow-up. It is suggested to pay attention to the loss of reduction and osteolysis of clavicular plate in clinical follow-up.

Estudio comparativo de la distancia coracohumeral en pacientes con patología degenerativa del subescapular y una población voluntaria asintomática / Comparative analysis of the coracohumeral distance between patients with degenerative subscapularis tendon pathology and a normal age-matched population

INTRODUCCIÓN: El pinzamiento subcoracoideo secundario a una distancia coracohumeral (DCH) disminuida, ha sido descrito como una posible etiología de las lesiones degenerativas del tendón del Subescapular (SSC), sin embargo, esa teoría aún es controversial. OBJETIVO: Evaluar si existe una diferencia significativa entre la DCH promedio de pacientes con patología degenerativa del SSC y un grupo control. MATERIALES Y MÉTODOS: Se diseñó un estudio de casos-controles y se estableció un tamaño muestral mínimo de 36 casos por grupo. De nuestra base de datos, y dentro de un periodo de 6 meses, se rescataron 46 Resonancias Magnéticas (RM) de hombro con patología degenerativa avanzada y/o roturas del SSC (grupo SSC). El grupo control fue conformado por 36 RM realizadas a voluntarios asintomáticos sin patología del mango rotador. Se incluyeron en ambos grupos solo pacientes entre 40 y 60 años. Se utilizó prueba de t para determinar las diferencias entre 2 grupos con un nivel de confianza del 95%. RESULTADOS: La edad promedio del grupo SSC fue 50,1 6,1 años y del grupo control 51,7 6,8 años, no existiendo diferencia estadísticamente significativa entre ambos (p » 0.43). La DCH promedio en el grupo SSC fue 8,58 mm [IC: 7,95­9,21 mm], y en el grupo control fue 11,04 mm [IC: 10,05­12,04 mm]. Al comparar la DCH, se encontró una diferencia estadísticamente significativa entre grupos (p » 0,00048). CONCLUSIÓN: Nuestros resultados respaldan la existencia de una asociación estadísticamente significativa entre una DCH disminuida y la presencia de patología degenerativa del SSC. NIVEL DE EVIDENCIA: III (Estudio de casos y controles).

BACKGROUND: The incidence of subscapularis tears is increasing as diagnostic imaging and arthroscopic technology improves. Decreased coracohumeral distance (CHD) with associated Subcoracoid Impingement is thought to be one, potential etiology for these lesions. OBJECTIVE: The purpose of this study was to identify the association between reduced CHD and degenerative pathology of the subscapularis tendon. METHODS: A comparative case-control study was performed. The sample size required to determine significance was calculated to be 36 cases. In total, 46 patients with severe degenerative SSC tendinopathy or subscapularis tears on magnetic resonance imaging (MR) were collected consecutively from our database (SSC group). The control group consisted of 36 asymptomatic volunteers undergoing shoulder MR. Only patients between 40 and 60 years of age were included. An independent t-test was used to determine the statistical significance between the two groups (with a 95% level of confidence). RESULTS: No statistically relevant difference was found between the average age of the two groups (50.1 6.1 and 51.7 6.8; p » 0.43). In the control group, the mean CHD was found to be 11.04 mm [CI:10.05­12.04 mm] and was 8.58 mm [CI: 7.95­9.21 mm] in the subscapularis group. The statistical analysis, comparing the CHD showed a significant difference between groups (p » 0.00048). CONCLUSION: This study supports the conclusion that degenerative subscapularis pathology is associated with narrowed coracohumeral distance, when compared with an asymptomatic age-matched group. LEVEL OF EVIDENCE: III (case-control study).

Análisis morfométrico de la apófisis coracoides mediante tomografía computarizada en Chile / Morphometric coracoid process analysis by computed tomography in Chile

OBJETIVO: Determinar la morfometría de la apófisis coracoides (Cor) mediante tomografía computarizada de hombro (TC hombro) en población chilena. MÉTODO: 162 TC hombro (90 género femenino y 72 masculino), edad promedio 55,9 20,2 años, fueron analizadas mediante sistema computacional IMPAX. RESULTADOS: Largo total Cor promedio de 41,0 2,5 mm. Largo promedio del pilar superior de 20,5 2 mm. Altura media pilar superior de 9,2 1,2 mm. Ancho promedio pilar superior de 10,3 1,5 mm. Altura media de la base de 13,4 1,8 mm. CONCLUSIÓN: En nuestra población el pilar superior es más ancho que alto y el largo total de Cor es aproximadamente el doble del largo del pilar superior. Todas las dimensiones de Cor son mayores en el género masculino versus femenino. Al comparar la morfometría de Cor, nuestra población es similar a otros grupos étnicos según lo descrito en la literatura. Nivel de evidencia: III.

PURPOSE: Define the morphometric measurements of the coracoid process (Cor) in Chilean population through the analysis of shoulder computed tomography (shoulder CT) METHOD: 162 shoulder TC (90 females and 72 males), average age 55.9 20.2 years, were analyzed by IMPAX software. RESULTS: The mean total Cor length was of 41.0 2.5 mm. Average upper pillar length was 20.5 2 mm. The mean upper pillar height was 9.2 1.2 mm. The mean upper pillar width was 10.3 1.5 mm. Average base height was 13.4 1.8 mm. CONCLUSIONS: In our population, upper pillar is wider than high and the total Cor length is approximately twice than upper pillar length. All Cor dimensions are greater in males versus females. The Cor morphometric measurements in our population is similar to other ethnic groups as described in the literature. Level of evidence: III.