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Shoulder| Volume 30, ISSUE 8, P1915-1923, August 01, 2021
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Comparison of single versus double TightRope system in the treatment of acute acromioclavicular joint dislocation
Feng Gu, MD 1
1 Authors Feng Gu and Lei Tan contributed equally to this paper as co-first authors.
Feng Gu
Department of Orthopedics, First Hospital of Jilin University, Changchun, China
Lei Tan, MD 1
Lei Tan
Tiejun Wang, MD
Tiejun Wang
Qiangqiang Wen, MS
Qiangqiang Wen
Zilong Su, MS
Zilong Su
Zhenjiang Sui, MS
Zhenjiang Sui
Tiecheng Yu, MD
Tiecheng Yu
Reprint requests: Tiecheng Yu, MD, Department of Orthopedics, First Hospital of Jilin University, Changchun 130021, China.
Open AccessPublished:November 04, 2020DOI:https://doi.org/10.1016/j.jse.2020.10.002
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Reconstruction of the coracoclavicular (CC) ligament using a single TightRope (ST) system has some complications. We attempted to use a double TightRope (DT) system to reduce complications and obtain the ideal therapeutic effect.
This investigation aimed to compare the ST and DT systems in terms of efficacy and safety in treating acromioclavicular (AC) joint dislocation.
Sixty-six cases of acute AC joint dislocation between January 2013 and January 2018 were retrospectively reviewed. All patients were divided into 2 groups based on treatment with the ST or DT system. Patients were evaluated radiologically and clinically using the Disability of Arm, Shoulder, and Hand, Constant, and visual analog scale scores as clinical outcome measures at 1 day, 3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. The CC distance and displacement ratio were assessed radiologically.
The mean follow-up period was 49 months. Satisfactory clinical outcomes were obtained after CC fixation in both groups. No intergroup difference was found regarding the visual analog scale (P = .80), Disability of Arm, Shoulder, and Hand (P = .42), or Constant score (P = .28) at 2 years. However, there was a significant difference in the displacement ratio at 6 weeks (P < .0001), 3 months (P < .0001), 6 months (P < .0001), 1 year (P < .0001), and 2 years (P < .0001) postoperatively between the 2 groups. There were 3 complications in the ST group, including 1 case of secondary coracoid fracture, 1 case of AC joint arthrosis combined with ossification of the CC ligaments, and 1 case of clavicular erosion. All complications occurred in the ST group.
Both surgical methods are effective in treating AC joint dislocation, but the DT system is more reliable for reduction maintenance.
Retrospective Cohort Comparison
Treatment Study
coracoclavicular ligament
TightRope system
AC dislocation
Dislocation of the acromioclavicular (AC) joint represents a spectrum of soft tissue structure disruptions that can result in acute pain around the joint, chronic pain, and changes in shoulder biomechanics resulting in long-term disability. The AC joint is stabilized by the coracoclavicular (CC) ligaments, joint capsule, and trapezio clavipectoral fascia. The CC ligaments are one of the most important anatomic structures for maintaining stability of the AC joint;
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thus, recent surgical treatments for dislocation of the AC joint have focused on CC interval fixation.
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Arch Orthop Trauma Surg. 2016; 136: 763-770https://doi.org/10.1007/s00402-016-2437-5
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Recently, reconstruction of the CC ligaments using an adjustable-loop-length suspensory fixation device was introduced as a surgical technique.
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The adjustable-loop-length suspensory fixation device can be used to treat CC ligament disruption, and it lends stability to the AC joint by supplying suspensory fixation between the clavicle and the coracoid process.
CC fixation using an adjustable-loop-length suspensory fixation device has shown promising results in previous studies.
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However, some problems associated with the adjustable-loop-length suspensory fixation device, including increases in the CC distance over time, pullout of the clavicular or coracoid buttons at the attachment sites, and fracture of the clavicle, have also been reported.
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One reason for CC interval reduction failure is that a single fixation system cannot restore the native CC ligament anatomy.
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Johnson S.T.
Rios C.G.
Dumonski M.L.
Arciero R.A.
A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction.
Native CC ligaments have anatomic attachments distinct from those in this system, which results in altered AC joint stability and functionality. The CC ligament complex is composed of the conoid and trapezoid ligaments, which are primary shoulder suspensory ligaments. Although structurally similar, these ligaments are different with respect to function and orientation, thereby mediating AC joint stability. Ideal reconstruction methods should roughly replicate the trapezoid and the conoid of the CC ligament complex to ensure that a normal CC interval is maintained until the soft tissue around the CC ligaments fully heals. Therefore, in the present study, we used 2 TightRope (an adjustable-loop-length suspensory fixation device) systems to reconstruct the CC ligaments and thereby achieve ideal fixation and avoid complications.
The purpose of this investigation was to evaluate radiological and clinical outcomes of CC fixation using the single TightRope (ST) or double TightRope (DT) system for acute AC dislocation and to report intraoperative and postoperative complications. Our hypothesis was that AC reconstruction using the DT system would provide satisfactory shoulder function restoration and acceptable radiological outcomes with minimal complications.
This was a retrospective study of clinical cases of acute AC joint dislocation diagnosed between January 2013 and January 2018 at our hospital. AC joint dislocation was diagnosed based on both clinical and radiographic assessments within a 3-day period after the original injury, and surgery was performed within 2 weeks after injury. Injuries were defined as Rockwood classification
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grade III when both the AC ligament and the CC ligaments were torn, the attachment point of the deltoid and trapezius muscles was torn, and the distal clavicle was unstable in both the horizontal and vertical planes. The inclusion criteria were as follows: (1) acute AC joint dislocation ranked higher than grade III (grade III not included) in the Rockwood classification system; (2) no prior shoulder injuries or surgeries; (3) no related injuries; (4) treatment with the ST or DT system; and (5) a minimum of 2 years of follow-up. All patients were treated by 1 surgeon in this study. The exclusion criteria were as follows: (1) grade I, II, III, or VI subluxation/dislocation of the AC joint; (2) open AC joint dislocation; (3) combination with vascular or neural injury; (4) dislocation for more than 3 days or chronic AC joint dislocation; (5) ipsilateral shoulder injury; (6) combination with coracoid process fracture or scapulothoracic dissociation of the injured shoulder; (7) history of surgery on the injured shoulder; and (8) limited life expectancy due to significant medical comorbidity or other contraindications to surgery.
We retrospectively analyzed 66 patients meeting these inclusion criteria in this study; 34 patients were treated with the ST system, whereas 32 patients were treated with the DT system. Sixteen shoulders were excluded based on the exclusion criteria during the time period of the study.
In the present study, all patients were treated with the TightRope system. The TightRope system is an adjustable-loop-length suspensory fixation device. Both ends of this device consist of an oblong coracoid button and a round clavicular button, and the 2 metal buttons are connected by a No. 5 FiberWire. The coracoid button engages under the coracoid process through the coracoid tunnel, and the clavicular button lies over the clavicle between the insertion sites of the 2 CC ligaments.
Although the surgical technique has been previously described in detail,
Zhao Y.
Tan L.
Tang W.
Yu T.
A new coracoclavicular guider for minimally invasive anatomic coracoclavicular reconstruction with two TightRope systems in acute acromioclavicular joint dislocation.
Sci Rep. 2019; 9: 14452https://doi.org/10.1038/s41598-019-51119-7
it can be briefly summarized as follows.
In the DT group, the first conoid clavicular and coracoid tunnels were made in the distal clavicle and coracoid base, respectively, and the second conoid clavicular and coracoid tunnels were made in the distal clavicle and coracoid base, respectively (Fig. 1).
In the ST group, a clavicular tunnel was created approximately 2 cm medial to the lateral edge of the clavicle. The coracoid tunnel was created at the central portion of the coracoid base.
Figure 1Placement of the conoid and trapezoid clavicular tunnels in the distal clavicle and coracoid base, respectively. (A) Marking of the distal clavicle for conoid and trapezoid clavicular tunnel placement. The center of this part of the clavicle was marked in red for conoid clavicular tunnel placement on top of the clavicle. The center of the red point to the distal end of the clavicle was marked in yellow for trapezoid clavicular tunnel placement on top of the clavicle. (B) Marking of the coracoid base for conoid and trapezoid coracoid tunnel placement. The conoid coracoid tunnel was placed at the posterior aspect of the coracoid base, 5 mm lateral to the medial border, as indicated by the red point. The trapezoid coracoid tunnel was placed 5 mm medial to the lateral border of the coracoid, as indicated by the yellow point. There was a >10-mm bony bridge between the 2 tips.
The oblong button of the TightRope was advanced through the tunnels from the coracoid to the clavicle. The TightRope suture tails were pulled to advance the round button under the coracoid until the reduction of the clavicle was noted to be satisfactory under direct visualization. Finally, the TightRope was tightened. The sutures were tied over the top of the TightRope using a surgeon's knot and 4 additional half-hitches.
Patients were asked to use shoulder immobilizers for 3 weeks, keeping them on except for when bathing or performing exercises to improve elbow extension and flexion. Patients were only allowed movement below shoulder height for the first 6 weeks, after which full movement was permitted. Patients were instructed to avoid any heavy resistance work for 3 months postoperatively.
Before surgery and at the follow-up visits 1 day, 3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery, images in the Zanca view were acquired. The Disability of Arm, Shoulder, and Hand,
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and visual analog scale scores were used as primary assessments by an independent reviewer to gauge shoulder function in these patients. In addition, the CC distance and displacement ratio were assessed radiologically. The CC distance, defined as the distance from the anteroinferior border of the clavicle to the superior border of the coracoid process, was determined based on standard anteroposterior images of the AC arch obtained both preoperatively and at the final follow-up for each shoulder (Fig. 2). The displacement ratio was defined as the value calculated by dividing the difference in the CC distance between the affected and unaffected sides by the CC distance on the unaffected side. All X-ray films were of the Zanca view, which is shot with the X-ray beam placed 10° cephalad to the perpendicular plane.
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Figure 2Representative preoperative and postoperative X-rays from the 2 groups. (A) Preoperative anteroposterior radiograph showing acute acromioclavicular joint dislocation type V according to the Rockwood classification. Coracoclavicular (CC) distance: vertical distance measured between the uppermost border of the coracoid process and the lateral aspect of the conoid tubercle. (B) Postoperative anteroposterior radiograph showing satisfactory CC reconstruction using the double TightRope system. (C) Postoperative anteroposterior radiograph showing satisfactory CC reconstruction using the single TightRope system.
Quantitative data are presented as the mean ± standard deviation. Furthermore, comparison of continuous variables was performed using the Mann-Whitney U test, whereas categorical data were analyzed using the χ2 test. All statistical analyses were conducted using SPSS 18.0 (IBM Corp., Armonk, NY, USA) software. P < .05 was considered to indicate statistical significance.
Group ST consisted of 22 men and 12 women, with a mean age of 44.7 years (range, 19-67 years) at the time of surgery, and group DT consisted of 20 men and 12 women, with a mean age of 44.8 years (range, 15-62 years) at the time of surgery (Table I). Patients were followed up for 24-82 (mean, 49) months. Clinical and radiologic analyses were performed for 66 patients. Patient demographics are summarized in Table I. No statistically significant differences were found between the 2 groups with regard to age (P = .99), sex (>.99), involved side (P = .09), injury mechanism (P = .27), interval from initial trauma to surgery (P = .23), or Rockwood classification (P = .61) (Table I).
Table IPatient demographics
Group ST
Group DT
Sample size (n) 34 32
Age (yr), mean ± SD (range) 44.7 ± 14.9 (19-67) 44.8 ± 11.9 (15-62) .99
Sex: male/female 22/12 20/12 >.99
Dominant arm, n (%) 16 (47.1) 22 (68.8) .09
Mean time to surgery, days ± SD (range) 1.9 ± 1.1 (1-3) 1.6 ± 0.80 (1-3) .23
Grade of AC dislocation, n (%) .61
IV 14 (41.2) 11 (34.4)
V 20 (58.8) 21 (65.6)
Causes of injury, n (%) .27
Car accident 8 (23.5) 6 (18.8)
Sports activity 2 (5.9) 6 (18.8)
Fall from a height 24 (70.6) 20 (62.5)
SD, standard deviation; AC, acromioclavicular; ST, single TightRope; DT, double TightRope.
Functional results
Patients resumed their former work with a mean time to the resumption of work of 7.0 ± 0.9 (range, 6-8) weeks in group ST and 6.8 ± 0.8 (range, 6-8) weeks in group DT, and there was no significant difference between the 2 groups (P = .29, 95% confidence interval [CI]: −0.63 to 0.19). At the final follow-up evaluation, there was no significant difference between the 2 groups in the visual analog scale (P = .80, 95% CI: −0.35 to 0.26), Disability of Arm, Shoulder, and Hand (P = .42, 95% CI: −1.10 to 0.46), or Constant (P = .28, 95% CI: −2.31 to 0.67) score at 2 years after surgery (Supplementary Table S1). No severe functional limitations were found in group ST or DT. Thus, both the ST and DT systems demonstrated good therapeutic efficacy in the repair of shoulder function. The functional outcomes were similar between the 2 devices.
Radiographic results
We followed all patients in the 2 groups for at least 2 years, and we reviewed the patients at the following timepoints: 1 day, 3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. The mean CC vertical distance was classified according to the grade of AC dislocation (Supplementary Table S2). The mean CC distance on the affected side in group ST was 15.7 ± 3.4 (range, 5.5-22.1) mm preoperatively, and it increased by 88.7% ± 31.2% (range, 41.3%-138.2%) on average compared with that on the unaffected side before surgery. The mean CC distance on the affected side in group DT was 15.9 ± 3.3 (range, 9.6-21.8) mm preoperatively, and it increased by 91.3% ± 30.4% (range, 40.8%-135.4%) on average compared with that on the unaffected side before surgery. Radiological assessment revealed the complete reduction of the AC joint postoperatively in both groups, and there was no significant difference in performance between the 2 surgical methods on imaging 1 day after the operation (P = .35) (Table II).
Table IIComparison of displacement
Time Group
Preoperatively
Postoperatively
Group ST (mm) 7.4 ± 2.9 (2.1-12.3) 0.1 ± 0.2 (−0.2 to 1.1) 0.3 ± 0.1 (0.1-0.6) 2.4 ± 1.5 (0.3-5.8)∗ 2.9 ± 1.4 (0.4-5.7)∗ 3.1 ± 1.5 (0.4-6.5)∗ 3.1 ± 1.5 (0.4-6.5)∗ 3.2 ± 1.5 (0.4-6.4)∗
Group DT (mm) 7.6 ± 2.7 (3.2-12.5) 0.1 ± 0.2 (−0.1 to 0.8) 0.2 ± 0.2 (0-0.8) 0.3 ± 0.2 (0.1-0.9)∗ 0.4 ± 0.2 (0.1-1.1)∗ 0.4 ± 0.2 (0.2-1.1)∗ 0.6 ± 0.2 (0.2-1.0) 0.7 ± 0.2 (0.4-1.2)∗
P value .87 .35 .05 <.0001∗ <.0001∗ <.0001∗ <.0001∗ <.0001∗
t value 0.16 0.95 1.97 19.33 9.75 10.00 9.63 9.58
95% CI −1.27 to 1.49 −0.15 to 0.05 −0.14 to 0.00 5.63 to 6.92 −3.03 to −2.00 −3.21 to −2.14 −3.13 to −2.06 −3.10 to −2.03
ST, single TightRope; DT, double TightRope; CI, confidence interval.
Values are mean ± standard deviation (range). P < .05 was considered statistically significant and marked with "∗."
We calculated the displacement ratio as a percentage by dividing the difference in the CC distance between the affected and unaffected sides by the CC distance on the unaffected side. There was no significant difference in the mean displacement ratio preoperatively between the 2 groups (P = .73) (Table III). However, the mean displacement ratio at 1 day, 3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively in group ST was 1.7% ± 2.3% (range, −2.1% to 5.4%), 3.1% ± 1.4% (range, 1.1%-6.1%), 28.7% ± 17.8% (range, 8.4%-71.8%), 35.3% ± 17.1% (range, 11.3%-12.4%), 37.7% ± 7.8% (range, 12.9%-74.1%), 38.0% ± 18.0% (range, 10.8%-76.6%), and 38.7% ± 18.0% (range, 11.8%-80.3%), respectively. The mean displacement ratio at 1 day, 3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively in group DT was 1.2% ± 2.2% (range, −2.0% to 9.4%), 2.35 ± 2.0% (range, 0%-9.6%), 4.2% ± 1.8% (range, 1.1%-10.1%), 5.1% ± 2.1% (range, 1.8%-13.0%), 5.3% ± 2.2% (range, 2.1%-13.5%), 6.7% ± 2.5% (range, 2.6%-11.6%), and 8.0% ± 2.5% (range, 4.4%-14.3%), respectively. There was a significant difference in the displacement ratio at 6 weeks (P < .0001), 3 months (P < .0001), 6 months (P < .0001), 1 year (P < .0001), and 2 years (P < .0001) postoperatively between the 2 groups (Table III). We found that the CC distance was significantly increased after 6 weeks in group ST (P < .0001), whereas the CC distance changed much less in group DT.
Table IIIComparison of displacement ratio
Group ST (%) 88.7 ± 31.2 (41.3-138.2) 1.7 ± 2.3 (−2.1 to 5.4) 3.1 ± 1.4 (1.1-6.1) 28.7 ± 17.8 (8.4-71.8)∗ 35.3 ± 17.1 (11.3-12.4)∗ 37.7 ± 7.8 (12.9-74.1)∗ 38.0 ± 18.0 (10.8-76.6)∗ 38.7 ± 18.0 (11.8-80.3)∗
Group DT (%) 91.3 ± 30.4 (40.8-135.4) 1.2 ± 2.2 (−2.0 to 9.4) 2.3 ± 2.0 (0-9.6) 4.2 ± 1.8 (1.1-10.1)∗ 5.1 ± 2.1 (1.8-13.0)∗ 5.3 ± 2.2 (2.1-13.5)∗ 6.7 ± 2.5 (2.6-11.6)∗ 8.0 ± 2.5 (4.4-14.3)∗
t value 0.35 0.82 1.82 7.78 9.91 10.21 9.72 9.56
95% CI −12.66 to 18.04 −0.65 to 1.56 −1.63 to 0.08 −30.85 to −18.24 −36.28 to −24.10 −38.66 to −26.01 −37.70 to −24.85 −37.21 to −24.35
There were 3 complications in this study. There was 1 case of secondary coracoid fracture at the coracoid tunnel combined with fixation failure (Fig. 3). This patient was female and had initially been injured by falling from a height, and we had chosen the ST system to fix the AC joint in the first operation. The patient's postoperative CC distance had recovered well, but when the patient was re-examined after 6 weeks, we found a secondary coracoid fracture and fixation failure. This patient underwent a second operation with the DT system. After the second operation, the patient's CC distance recovered well. On follow-up, we found no complications, such as fixation failure or an obvious secondary increase in the CC distance. There was 1 case of AC joint arthrosis combined with ossification of the CC ligaments in a 47-year-old male patient 6 months after surgery (Fig. 4). The CC interval on the affected side preoperatively and 1 day, 3 weeks, and 6 weeks postoperatively was 13.5, 8.3, 8.5, and 13.5 mm, respectively. The patient had been treated with the ST system, and although obvious ossification of the CC ligaments was found on X-ray examination, the patient had no shoulder movement limitations. There was 1 case of cortical surface erosion in a 56-year-old male patient 1 year after surgery (Fig. 5). The patient had been treated with the ST system, and radiography showed an increased CC interval (CC interval on the affected side preoperatively at 1 day, 3 weeks, and 6 weeks postoperatively of 15.4, 7.6, 7.7, and 13.4 mm, respectively) caused by superior cortical surface erosion of the clavicle by the clavicular button and part of the plate sunk into the clavicle. The clavicular hole was obviously larger than before. The latter 2 patients strictly followed the rehabilitation plan, without any additional motion or other external forces.
Figure 3Preoperative and postoperative X-rays of the patient with fixation failure. (A) Preoperative anteroposterior radiograph showing acute acromioclavicular joint dislocation type V according to the Rockwood classification. (B) Postoperative anteroposterior radiograph showing satisfactory coracoclavicular reconstruction using the single TightRope system. (C, D) Secondary coracoid fracture at the coracoid tunnel (white arrow) combined with fixation failure 6 weeks after the operation.
Figure 4Preoperative and postoperative X-rays of the patient with ossification of the coracoclavicular (CC) ligaments. (A) Preoperative anteroposterior radiograph showing acute acromioclavicular joint dislocation type V according to the Rockwood classification. (B) Postoperative anteroposterior radiograph showing satisfactory CC reconstruction using the single TightRope system. (C) The CC distance was increased at 3 months compared with 1 day postoperatively on anteroposterior radiography. (D) The CC distance was increased at 6 months compared with 1 day postoperatively on anteroposterior radiography, and ossification of the CC ligaments was observed (white arrow).
Figure 5Preoperative and postoperative X-rays of the patient with clavicular cortical surface erosion. (A) Preoperative anteroposterior radiograph showing acute acromioclavicular joint dislocation type V according to the Rockwood classification. (B) Postoperative anteroposterior radiograph showing satisfactory coracoclavicular (CC) reconstruction using the single TightRope system immediately after the operation. (C) Anteroposterior radiograph showing an increased CC interval caused by superior cortical surface erosion of the clavicle (arrow) by the clavicular button and part of the plate sinking into the clavicle at 2 years compared with 1 day postoperatively on anteroposterior radiography. The clavicular tunnel was obviously larger than before.
This is the first comparative study on the application of 1 vs. 2 TightRope systems in the treatment of acute AC joint dislocation. In this study, satisfactory clinical outcomes were obtained after CC fixation in both groups. However, radiological outcomes revealed a significant difference in the CC distance 6 weeks postoperatively (P < .0001). The DT system showed much less change in the CC distance. This finding indicates that the DT system was more stable in maintaining the CC distance.
There was a significant difference in the mean displacement ratio at 6 weeks (P < .0001), 3 months (P < .0001), and 6 months (P < .0001) between the 2 groups. We found that the displacement ratio changed most obviously in group ST within 6 weeks postoperatively. Six weeks later, the CC distance was relatively stable in group ST. This may have been related to the time required for ligament repair (6 weeks) and the fact that the CC distance often changes little after 6 weeks. According to the trend of the CC distance data, we believe that the period of greatest instability after AC joint surgery is within 6 weeks postoperatively and that displacement and fixation failure occur mostly within 3-6 weeks.
The 2 components of the native CC ligaments have different anatomic attachments and provide vertical and horizontal stability for the AC joint. However, the ST system provides only single-point vertical fixation and cannot restore the horizontal stability of the AC joint. Compared with the horizontal instability of the ST system, biomechanical experiments have proven that the DT system provides good horizontal stability.
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There was 1 patient with a secondary coracoid process fracture in group ST. The main reason for treatment failure in this case was a fall on the right shoulder 6 weeks after the primary surgery. Furthermore, in this case, another reason for the CC interval reduction failure was that the coracoid hole was not at the coracoid base, and its position was obviously forward (Fig. 3, C and D, white arrow). The coracoid base is known to be anatomically larger and wider than the coracoid forepart, and positioning of the coracoid hole in the coracoid forepart is weaker than that in the coracoid base.
There was 1 case of AC joint arthrosis combined with ossification of the CC ligaments, and we suspected that this may also have been related to insufficient fixation of the ST system.
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Maderni A.
Bruno L.
Mariotti U.
Suture rupture in acromioclavicular joint dislocations treated with flip buttons.
Micromovement of joints and stimulation of ligaments may cause ossification of the ligaments.
Jari R.
Costic R.S.
Rodosky M.W.
Debski R.E.
Biomechanical function of surgical procedures for acromioclavicular joint dislocations.
Jobmann S.
Buckup J.
Colcuc C.
Roessler P.P.
Zimmermann E.
Schuttler K.F.
Anatomic ligament consolidation of the superior acromioclavicular ligament and the coracoclavicular ligament complex after acute arthroscopically assisted double coracoclavicular bundle stabilization.
Jeon Y.S.
Kim R.G.
Arthroscopic-assisted coracoclavicular ligament reconstruction for acute acromioclavicular dislocation using 2 clavicular and 1 coracoid cortical fixation buttons with suture tapes.
Arthroscopy. 2017; 33: 1458-1466https://doi.org/10.1016/j.arthro.2017.02.003
The increase in the CC distance in the patient also confirmed this point of view.
There was also 1 case of clavicular erosion in our study. Previous research
Guttmann D.
Paksima N.E.
Zuckerman J.D.
Complications of treatment of complete acromioclavicular joint dislocations.
Instr Course Lect. 2000; 49: 407-413
Jerosch J.
Filler T.
Peuker E.
Greig M.
Siewering U.
Which stabilization technique corrects anatomy best in patients with AC-separation? An experimental study.
Knee Surg Sports Traumatol Arthrosc. 1999; 7: 365-372
Metzlaff S.
Rosslenbroich S.
Forkel P.H.
Schliemann B.
Arshad H.
Raschke M.
Surgical treatment of acute acromioclavicular joint dislocations: hook plate versus minimally invasive reconstruction.
has demonstrated that the synthetic materials used for CC cerclage have a sawing effect due to rotational motion of the clavicle with damage to the lateral clavicle and the coracoid process, and this effect is greater when the ST system is applied. The stress distribution on the clavicle with the use of the DT system prevents such clavicular erosion.
The use of CC guides increased the accuracy of TightRope placement and reduced the incidence of complications, such as fractures of the distal clavicle and the coracoid process, which are frequently reported complications in open and arthroscopic reconstruction methods.
Clavert P.
Meyer A.
Boyer P.
Gastaud O.
Barth J.
Duparc F.
Complication rates and types of failure after arthroscopic acute acromioclavicular dislocation fixation. Prospective multicenter study of 116 cases.
Orthop Traumatol Surg Res. 2015; 101: S313-S316https://doi.org/10.1016/j.otsr.2015.09.012
Dyrna F.
Berthold D.P.
Feucht M.J.
Muench L.N.
Martetschläger F.
The importance of biomechanical properties in revision acromioclavicular joint stabilization: a scoping review.
Knee Surg Sports Traumatol Arthrosc. 2019; 27: 3844-3855https://doi.org/10.1007/s00167-019-05742-6
Kennedy B.P.
Rosenberg Z.S.
Alaia M.J.
Samim M.
Alaia E.F.
Radiographic features and complications following coracoclavicular ligament reconstruction.
Skeletal Radiol. 2020; 49: 955-965https://doi.org/10.1007/s00256-020-03375-2
Pan X.
Lv R.Y.
Lv M.G.
Zhang D.G.
TightRope vs clavicular hook plate for Rockwood III-V acromioclavicular dislocations: a meta-analysis.
Orthop Surg. 2020; 12: 1045-1052https://doi.org/10.1111/os.12724
Rush L.N.
Lake N.
Stiefel E.C.
Hobgood E.R.
Ramsey J.R.
O'Brien M.J.
Comparison of short-term complications between 2 methods of coracoclavicular ligament reconstruction: a multicenter study.
Orthop J Sports Med. 2016; 4 (2325967116658419)https://doi.org/10.1177/2325967116658419
First, the relatively small sample size and the retrospective design of the study may have affected the statistical results. Second, the DT system still could not restore the native CC ligaments anatomically and allow the ligaments to fully recover. However, its mode of reconstruction with 2 sutures does provide greater stability. The high rate of early radiological complications and the obvious change in the CC distance in patients treated with the ST system are sufficient to show the need to modify the ST system.
We conclude that both the ST and DT systems are effective in treating AC joint dislocation but that the DT system is more reliable for reduction maintenance.
Feng Gu and Lei Tan contributed equally to this paper. Tiecheng Yu conceived the experiments, Feng Gu and Lei Tan wrote the main manuscript text, Tiejun Wang prepared the figures, and Tiecheng Yu edited the draft. Qiangqiang Wen, Zilong Su and Zhenjiang Sui analyzed the data. All authors reviewed the manuscript.
The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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Supplementary Table S1
This study was carried out in accordance with the guidelines for the care for human subjects adopted by the First Hospital of Jilin University. The study protocol was approved by the Research Ethics Committee of the First Hospital of Jilin University (ref. no. 2020-360), and written informed consent was obtained from all participants.
© 2020 The Authors. Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees.


FLORENCE, S.C. - On one side of the road the crops stood 15 feet high, their long green leaves a rustling fortress of foliage.
On the other side, the crops were 3 feet high, with smaller leaves but large stems packed into tight rows.
The crops are the same - both are sorghum, a grass with a variety of uses for food and energy. But they look different because Stephen Kresovich, a geneticist at Clemson University, wants them to. Of the 30,000 genes in a sorghum plant, Kresovich changed four of them.
He hopes to burn the tall sorghum for electricity - that's why he wanted them tall, with lots of long, green leaves packed with energy. The short sorghum will go to feed hogs in North Carolina - which is why he wanted them short, with all of the good stuff packed into the grain, the part the hogs actually eat.
Kresovich is the new director of the Advanced Plant Technology Lab at Clemson's Pee Dee Research and Education center in Florence. State lawmakers have given the lab $8 million over the past two years, money to renovate a 25-year-old research building in Florence and to hire a slew of scientists. The idea, Kresovich said, is to take advantage of the "revolution going on in biology" when it comes to genetics.
Lots has been written about the impact of personalized medicine - for example, about mapping a person's genome to come up with customized medical treatments - and Kresovich said the same thing is happening in plants. In 2001, it cost about $100 million to map a genome - all of the genes in a plant or person. Now it costs less than $10,000. Scientists project the price will eventually fall to $1,000, according to the National Human Genome Research Institute.
"We want to generate the biological data and computational power to find gold nuggets in the genome," Kresovich said.
Kresovich and state lawmakers say they hope some of those "gold nuggets" could transform South Carolina's economy. If Kresovich can breed a variety of sorghum that can be used for electricity, he says it could open the door for companies to locate in South Carolina to use the technology.
"It's like cartography, like being an explorer in the 1500s on the new worlds, except I'm not physically stepping on things," Kresovich said. "We have the perfect opportunity for engines of economic development. The opportunity is here. Why not take advantage of that?"
The project includes a $3 million renovation of a 25-year-old science lab at Clemson's Pee Dee Research and Education Center. The work is scheduled to be completed by 2015. But Clemson is not waiting for that to start its research. In addition to Kresovich, the university has hired Ben Fallen and Shyam Tallury as the first of six plant breeders. Fallen works with soybeans, while Tallury works with peanuts.
Soybeans are a particularly important crop to South Carolina. In 2012, S.C. farmers planted 380,000 acres of soybeans - more than corn - worth $182 million, according to the USDA National Agriculture Statistics Service.
"Anything you pick up in a grocery store has soybean oil or some type of soybean product in it," Fallen said.
Researchers at the University of Missouri discovered a breed of soybean that has high levels of oleic acid. That's important because that acid means the soybean oil does not have to be hydrogenated, meaning it has less transfat, meaning it is more heart healthy.
But the problem is you can't grow the same soybeans in Missouri that you can grow in South Carolina - for a bunch of reasons, including climate and soil type. One of Fallen's projects is trying to breed a soybean variety that has high levels of oleic acid that can help it tolerate South Carolina's climate.
"Agriculture is sort of local. It's like politics. It has to be optimized for your environment," Kresovich said.
Fallen was hired in May, just in time to plant some soybeans in Florence. He said the breeding process can take eight to 10 years before a line is able to be released to the public.
State Sen. Kent Williams, D-Marion, said it is worth the wait. Williams is a member of the Senate budget subcommittee that approved the funding for the project. He said he hopes it will "expand the market for S.C. farm products."
A good example is peanuts. Ten years ago, South Carolina farmers planted 10,000 acres of peanuts, worth $3.1 million. Last year, they planted 110,000 acres of peanuts, worth $138 million.
"Finding those markets out there so they can sell these peanuts and get good wages, that's what Clemson has been about at this research center," Williams said. "I think this is money well spent."


The annual International Criminal Court summer school at the Irish Centre for Human Rights is the premiere summer school specializing on the International Criminal Court. The summer school allows participants the opportunity to attend a series of intensive lectures over five days. The lectures are given by leading academics on the subject and by legal professionals working at the International Criminal Court. The summer school is attended by legal professionals, academics, postgraduate students and NGOs. Participants are provided with a detailed working knowledge of the establishment of the Court, its structures and operations, and the applicable law. Participants are also given the opportunity to network with the speakers throughout the week. Lectures also speak to related issues in international criminal law, including: genocide, war crimes, crimes against humanity, the crime of aggression, universal jurisdiction, immunities, and the role of victims. We are delighted to announce that this year we will have a lecture on Africa and the ICC.
Dr. Kwadwo Appiagyei Atua- University of Ghana and University of Lincoln.
See here for the full programme. More information on the Summer School and details about registration can be found here, or email iccsummerschool@gmail.com.


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Q: What's about the relationship between mathematics and physics via Noether theorem? I am interesting in a brief introduction for mathematicians about what is the Noether Theorem, and what's about the relationship between and mathematics and physics, concerning this theorem, if there were examples being this theorem the interface between both territories.

Question. Are there some relationship or potentially/hypothetical relationships between mathematics and physics linked by the Noether Theorem? Please can you please explain it with your reasoning and mathematics, if it is possible. What were such examples (if from your interpretation there were such examples)? Thanks in advance.

The question isn't mine, is (myself) an interpretation of a question that was asked in a video.

redpajama_set_name: RedPajamaStackExchange


Having written, directed and edited features, television and commercials, William is an experienced filmmaker in all phases of production.
With extensive commercial experience, Will directed Coca-Cola "Beat The Heat" with popular singers Monica Brown & LeToya Luckett as well as Smirnoff "The Good Life Party" featuring Lance Gross of Tyler Perry fame. Other William Wedig commercial credits include and AT&T "New & Next" featuring up-and-coming artists St. Beauty, Chevy w/artist Ron Bass, Walmart, and Geico.
On TV, William's single-camera kids show, TEAM TOON, was produced for Cartoon Network and FremantleMedia, and is now on Netflix (US) and Amazon Prime (UK). As the series director, William Wedig directed 24 of 26 episodes of TEAM TOON starring Disney/ABC star Meg Donnelly (AMERICAN HOUSEWIFE, THE BROKEN ONES, ZOMBIES).
The shoot consisted of 145 shooting days, 550 script pages and over 5,000 individual shots.
William Wedig on the set of TEAM TOON.
William directed and edited the show Exposure: Sports Illustrated Swimsuit which starred Kate Upton, Brooklyn Decker, Irina Shayk, and 14 other supermodels. The show is available on the Playstation Network and DVD.
William's feature film FORGED (which he wrote, directed and edited) won the HBO Latino Film Festival and the Providence Latin American Film Festival. FORGED stars Emmy winner Margo Martindale (THE AMERICANS, AUGUST: OSAGE COUNTY), Jaime Tirelli (GIRLFIGHT, CARLITO'S WAY), and Manny Perez (HOMELAND, PRIDE AND GLORY, BLACKLIST).
William Wedig directed the feature film RISE OF THE DEAD distributed by Lions Gate Home Entertainment. The film has been described as a "smart and original take on an equally old genre" (Fangoria) and William's directing as "a breath of fresh air" (C.H.U.D.).
In short form comedy, William directed the short film series JACK LINK'S SASQUATCH WATCH with NFL star linebacker Clay Mathews III of the Greenbay Packers, Boomer Esiason, former-NFL star Amani Toomer, and the popular Jack Link's character: Sasquatch.
As series director on SPORTS ILLUSTRATED'S FUNNIEST PEOPLE IN SPORTS, Will directed sports figures as then Minnesota Vikings punter Chris Kluwe, award-winning female pro hockey player Hilary Knight, and professional surfer Anastasia Ashley.
William also directed the slick mockumentary for Russell Athletics entitles RUSSELL: DADLETES.
William Wedig directed the ESSENCE FESTIVAL: PRINCE TRIBUTE which screened in the Super Dome for tens of thousands of people.
William Wedig was the director on the music series NOISEMAKERS ON NOISEVOX featuring world-renowned music journalist and former-MTV VJ, John Norris. The show featured bands such as Warpaint (who were produced by John Frusciante of the Red Hot Chili Peppers), Temper Trap ("Sweet Disposition", "Need Your Love"), and Lady Gaga.
Although directing is William's primary focus and goal, he is also a professional editor with recognizable credits that include PBS/Time Inc. Studios TV Special JIMMY & ROSALYN CARTER WORK PROJECT, YAHOO! MAIL with Nicole Richie, CHEVY MALIBU with Isaac Mizrahi, The World Sports League tc shows for J-BAY, TRESTLES and U.S. OPEN for air on ABC and CBS, and TIME'S 100 MOST INFLUENTIAL PHOTOGRAPHS and TIME'S ONE DREAM.
He graduated with a degree in film from the School of Visual Arts in New York City and spends half his time with his wife in Brooklyn and half in Los Angeles.