The “coracoid tunnel view”: a simulation study for finding the optimal screw trajectory in coracoid base fracture fixation

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Abstract

Purpose

Coracoid fractures represent approximately 3–13% of all scapular fractures. Open reduction and internal fixation can be indicated for a coracoid base fracture. This procedure is challenging due to the nature of visualization of the coracoid with fluoroscopy. The aim of this study was to develop a fluoroscopic imaging protocol, which helps surgeons in finding the optimal insertion point and screw orientation for fixations of coracoid base fractures, and to assess its feasibility in a simulation study.

Methods

A novel imaging protocol was defined for screw fixation of coracoid base fractures under fluoroscopic guidance. The method is based on finding the optimal view for screw insertion perpendicular to the viewing plane. In a fluoroscopy simulation environment, eight orthopaedic surgeons were invited to place a screw down the coracoid stalk through the coracoid base and into the neck of 14 cadaveric scapulae using anatomical landmarks. The surgeons placed screws before and after they received an e-learning of the optimal view. Results of the two sessions were compared and inter-rater reliability was calculated.

Results

Screw placement was correct in 33 out of 56 (58.9%) before, and increased to 50 out of 56 (89.3%) after the coracoid tunnel view was explained to the surgeons, which was a significant improvement ( p < 0.001).

Conclusions

Our newly developed fluoroscopic view based on simple landmarks is a useful addendum in the orthopaedic surgeon’s tool box to fixate fractures of the coracoid base.

Electronic supplementary material

The online version of this article (10.1007/s00276-019-02274-z) contains supplementary material, which is available to authorized users.

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Most cited references 18

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Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments.

G Rios, Augustus Mazzocca, R Arciero (2007)

Recently acromioclavicular joint reconstruction techniques have focused on anatomic restoration of the coracoclavicular (CC) ligaments. Such techniques involve creating bone tunnels in the distal clavicle and coracoid. To define the anatomy of the human clavicle and coracoid process of the scapula, in order to guide surgeons in reconstructing the CC ligaments. Descriptive laboratory study. One hundred twenty (60 paired) cadaveric clavicles and corresponding scapulae (mean age +/- and standard deviation, 48.3 +/- 16.6 years) devoid of soft tissue were analyzed (dry osteology). Differences related to race and sex were recorded. Nineteen fresh-frozen cadaveric clavicles with intact CC ligaments were measured as well (fresh anatomic). The mean clavicle length was 149 +/- 9.1 mm. In the dry osteology group, the distance from the lateral edge of the clavicle to the medial edge of the conoid tuberosity in male and female specimens was 47.2 +/- 4.6 mm and 42.8 +/- 5.6 mm, respectively (P = .006). The distance to the center of the trapezoid tuberosity was 25.4 +/- 3.7 mm in males and 22.9 +/- 3.7 mm in females (P = .04). The ratio of the distance to the medial edge of the conoid tuberosity divided by clavicle length was 0.31 in males and females. This ratio for the trapezoid was 0.17 in both sexes. The mean coracoid length was 45.2 +/- 4.1 mm. The mean width and height of the coracoid process were 24.9 +/- 2.5 mm and 11.9 +/- 1.8 mm, respectively. No interracial differences in measurements were observed. In the fresh anatomic samples, the ratio of the distance to the conoid center to clavicle length was 0.24. This ratio for the trapezoid was 0.17. While absolute differences in the origin of the CC ligaments exist between men and women, the ratio of these origins to total clavicle length is constant. Clavicle length can be obtained intraoperatively. These findings allow the surgeon to predict the origin of the conoid and trapezoid ligaments accurately and to correctly create bone tunnels to reconstruct the anatomy of the CC complex.

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Fractures of the coracoid process.

M. Takahashi, K. Ogawa, Carolina A. Yoshida … (1996)

We reviewed 67 consecutive patients with fractures of the coracoid process, classifying them by the relationship between the fracture site and the coracoclavicular ligament. The 53 type-I fractures were behind the attachment of this ligament, and the 11 type-II fractures were anterior to it. The relationship of three fractures was uncertain. Type-I fractures were associated with a wide variety of shoulder injuries and consequent dissociation between the scapula and the clavicle. Treatment was usually by open reduction and fixation for type-I fractures and conservative methods for type-II. At follow-up of the 45 available patients, 87% had excellent results, with no significant differences between the operative and non-operative groups or between the type-I and type-II fractures. We consider that operative treatment should be reserved for patients with multiple shoulder injuries with severe disruption of the scapuloclavicular connection.

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Surgery for scapula process fractures

Jack Anavian, Coen Wijdicks, Lisa K Schroder … (2009)

Background Generally, scapula process fractures (coracoid and acromion) have been treated nonoperatively with favorable outcome, with the exception of widely displaced fractures. Very little has been published, however, regarding the operative management of such fractures and the literature that is available involves very few patients. Our hypothesis was that operative treatment of displaced acromion and coracoid fractures is a safe and effective treatment that yields favorable surgical results. Methods We reviewed 26 consecutive patients (27 fractures) treated between 1998 and 2007. Operative indications for these process fractures included either a painful nonunion, a concomitant ipsilateral operative scapula fracture, ≥ 1 cm of displacement on X-ray, or a multiple disruption of the superior shoulder suspensory complex. All patients were followed until they were asymptomatic, displayed radiographic fracture union, and had recovered full motion with no pain. Patients and results 21 males and 5 females, mean age 36 (18–67) years, were included in the study. 18 patients had more than one indication for surgery. Of the 27 fractures, there were 13 acromion fractures and 14 coracoid fractures. 1 patient was treated for both a coracoid and an acromion fracture. Fracture patterns for the acromion included 6 acromion base fractures and 7 fractures distal to the base. Coracoid fracture patterns included 11 coracoid base fractures and 3 fractures distal to the base. Mean follow-up was 11 (2–42) months. All fractures united and all patients had recovered full motion with no pain at the time of final follow-up. 3 patients underwent removal of hardware due to irritation from hardware components that were too prominent. There were no other complications. Interpretation While most acromion and coracoid fractures can be treated nonoperatively with satisfactory results, operative management may be indicated for displaced fractures and double lesions of the superior shoulder suspensory complex.

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Author and article information

Contributors

P. Kloen: +31205662655 , p.kloen@amsterdamumc.nl

Journal

Journal ID (nlm-ta): Surg Radiol Anat

Journal ID (iso-abbrev): Surg Radiol Anat

Title: Surgical and Radiologic Anatomy

Publisher: Springer Paris (Paris )

ISSN (Print): 0930-1038

ISSN (Electronic): 1279-8517

Publication date (Electronic): 4 July 2019

Publication date PMC-release: 4 July 2019

Publication date (Print): 2019

Volume: 41

Issue: 11

Pages: 1337-1343

Affiliations

[1 ]GRID grid.7177.6, ISNI 0000000084992262, Department of Orthopaedic Trauma Surgery, , Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, ; Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands

[2 ]GRID grid.7177.6, ISNI 0000000084992262, Department of Biomedical Engineering and Physics, , Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, ; Amsterdam, The Netherlands

Article

Publisher ID: 2274

DOI: 10.1007/s00276-019-02274-z

PMC ID: 6841653

PubMed ID: 31273419

SO-VID: e3711951-966d-4eca-aa43-6e6b2448f945

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 20 November 2018

Date accepted : 22 June 2019

Custom metadata

ScienceOpen disciplines: Surgery

Keywords: scapula,coracoid,fracture,screw fixation,fluoroscopy imaging,radiographic

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ScienceOpen disciplines: Surgery

Keywords: scapula, coracoid, fracture, screw fixation, fluoroscopy imaging, radiographic

The “coracoid tunnel view”: a simulation study for finding the optimal screw trajectory in coracoid base fracture fixation

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Fracture and Structural Integrity

Most cited references 18

Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments.

Fractures of the coracoid process.

Surgery for scapula process fractures

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