Abstract
Objective
To explore the clinical effect of cannulated screw fixation for coracoid process fractures of the scapula assisted by robot navigation combined with O-arm imaging.
Methods
A retrospective analysis was conducted of the clinical data from 19 patients with scapular coracoid process fractures who underwent surgical treatment at our center from January 2022 to July 2023. All the patients had their coracoid process fractures fixed with screws assisted by the robot navigation system combined with the O-arm imaging navigation system by experienced orthopedic surgeons. Three patients were excluded due to insufficient follow-up, and finally 16 patients were included in the study. The patients’ surgical conditions (operation time, intraoperative blood loss) and fracture healing time were recorded. During the outpatient follow-up 12 months after the operation, the Constant score was used to evaluate the function of the patients’ shoulder joints, and the Visual Analogue Scale (VAS) pain score was applied to assess the residual pain of the patients’ shoulder joints.
Results
All patients were followed for at least 12 months, with an average of 14.2 months (ranging 12 to 19 months). The average operation time of the 16 patients was 75.8 min (ranging from 52 to 98 min), and the average intraoperative blood loss was 47.3 ml (ranging from 28 to 75 ml). All 16 fractures healed without nonunion or loss of reduction, and the average healing time was 10.2 weeks (range, 8 to 14 weeks). One year after the operation, the shoulder joint functions of all 16 patients were good. The average Constant score was 90.5 points (ranging from 82 to 97 points), and the average VAS score of the shoulder joints was 1.0 points (ranging from 0 to 4 points). No cases of blood vessel or nerve injury related to surgical operation were found in all patients during the perioperative period and follow-up period.
Conclusion
In this retrospective case series, robot-assisted cannulated screw fixation with O-arm navigation for coracoid process fractures resulted in satisfactory fracture healing and shoulder function, with minimal blood loss and low perioperative complication rates. The proceduralized workflow may facilitate surgical standardization. Given the study’s exploratory nature and low level of evidence, further controlled studies are needed to confirm comparative advantages.
Introduction
The incidence of coracoid process fractures is relatively low, accounting for 3–13% of scapular fractures and 1% of all fractures [1]. Coracoid process fractures are rare injuries that are often overlooked on plain radiographs. Computed Tomography (CT) examination should be completed to avoid missing the diagnosis of coracoid process fractures [2].
The coracoid process is the attachment point of the pectoralis minor muscle, biceps brachii muscle, and coracobrachialis muscle. At the same time, it is also the origin of the coracoclavicular ligament, coracoacromial ligament, and coracohumeral ligament. It is an important structure that constitutes the superior shoulder suspensory complex (SSSC) and the stability of the shoulder joint [3, 4]. Therefore, once a coracoid process fracture occurs, it should be treated in a timely manner [5].
Choosing conservative treatment for coracoid process fractures may lead to complications such as external deformity, pain, nonunion, and acromioclavicular joint dislocation [6–8]. Young patients have high requirements for shoulder joint function. Especially for fractures at the base of the coracoid process, they tend to prefer surgical treatment.
Due to the relatively deep location of the coracoid process, the axillary artery, axillary vein, and brachial plexus nerves pass through the inferomedial side of its base. An inappropriate position of the internal fixation screw may lead to damage to blood vessels and nerves. With the continuous development of technology, the O-arm imaging navigation system has gradually been applied in orthopedic surgeries. It can provide the three-dimensional structure of the fracture site during the operation, offering surgeons clear three-dimensional images, which helps surgeons better determine the direction and position for screw placement and avoid damaging important structures.
At present, the O-arm imaging system is mainly applied in spinal surgery and joint surgery [9–11], and its application in trauma orthopedics is relatively limited. There are certain difficulties in intraoperative fluoroscopy and screw placement for coracoid process fractures, and robot navigation combined with the O-arm imaging system can largely address these problems. Our center has treated 16 patients with coracoid process fractures using robot navigation combined with the O-arm imaging system to assist with screw fixation; the details are reported as follows.
Materials and methods
General data of patients
A retrospective analysis was conducted on the clinical data of 19 patients with coracoid process fractures who underwent surgical treatment in our center from January 2022 to July 2023.
Inclusion criteria: 1. Acute traumatic coracoid process fracture; 2. Patients with a strong demand for prognostic function or associated SSSC injury; 3. Treatment with robot‑assisted cannulated screw fixation with O‑arm imaging; 4. Minimum follow‑up of 12 months.
Exclusion criteria: 1. Severe open fracture or severe multiple trauma; 2. Previous shoulder surgery or infection; 3. Follow‑up < 12 months.
After admission, all patients completed the radiological examinations including standard X-ray and CT scans. Three patients were excluded due to insufficient follow-up, and finally 16 patients were included in the study. Among them, there were 12 males and 4 females; age ranged from 25 to 58 years, with an average of 35.9 ± 9.1 years. According to Eyres classification of coracoid process fractures, there were 2 cases of type Ⅱ, 8 cases of type Ⅲ, 5 cases of type Ⅳ, and 1 case of type Ⅴ.
Among the 16 patients, 5 cases were caused by contact sports, 8 cases were caused by traffic accidents, 2 cases were caused by a fall from a height, and 1 case was caused by industrial injury. The time from injury to surgery for the 16 patients was 7.8 ± 2.8 days (Table 1). All the operations were performed by an experienced orthopedic surgeon, and the surgical method adopted was the fixation of coracoid process fractures with screws assisted by the robot navigation system combined with the O-arm imaging navigation system.
Table 1.
General characteristics of the patients
| ID | Gender | Age (years) | Eyres classification |
Mechanism of injury |
Time to surgery (days) |
|---|---|---|---|---|---|
| 1 | Male | 36 | Ⅲ | Contact sport | 9 |
| 2 | Female | 41 | IV | Traffic accident | 3 |
| 3 | Male | 28 | Ⅲ | Traffic accident | 8 |
| 4 | Male | 31 | Ⅲ | Contact sport | 7 |
| 5 | Male | 33 | IV | Traffic accident | 12 |
| 6 | Male | 40 | IV | Fall | 6 |
| 7 | Female | 29 | Ⅲ | Traffic accident | 10 |
| 8 | Male | 32 | Ⅲ | Contact sport | 10 |
| 9 | Male | 56 | Ⅱ | Traffic accident | 8 |
| 10 | Male | 25 | Ⅲ | Contact sport | 5 |
| 11 | Female | 38 | V | Traffic accident | 9 |
| 12 | Male | 58 | Ⅱ | Industrial injury | 11 |
| 13 | Female | 30 | Ⅳ | Fall from height | 4 |
| 14 | Male | 45 | Ⅲ | Traffic accident | 7 |
| 15 | Male | 27 | Ⅲ | Contact sport | 6 |
| 16 | Male | 42 | Ⅳ | Fall from height | 8 |
Operative planning and surgical technique
After the patient achieved satisfactory anesthesia, the "beach chair position" was maintained, and the affected scapula was elevated with a square cushion, the preoperative X-ray film was shown in Fig. 1a. After routine disinfection, concomitant injuries (e.g., acromioclavicular joint dislocation) were addressed first. A tracer was inserted, and the Tianji orthopedic robot was used. After fracture reduction, O‑arm scanning was performed, and the data were transferred to the robot workstation for planning the entry point and trajectory of the guide pin (Fig. 1b, c). The entry point of the guide pin was at the turning point behind the tip of the coracoid process and pointed towards the direction of the glenoid cavity at the root of the coracoid process. After the direction of the screw was planned, the robotic arm of the robot was activated. When the robotic arm moved to the entry point on the body surface, the guide pin was percutaneously inserted along the robotic arm, and then 1 to 2 3.5 mm cannulated screws were inserted along the guide pin to fix the coracoid process fracture Under robotic guidance, the guide pin was inserted percutaneously, followed by placement of 1–2 3.5-mm cannulated screws (Fig. 1 d, e). Under robotic guidance, the guide pin was inserted percutaneously, followed by placement of 1–2 3.5-mm cannulated screws (Fig. 1f).
Fig. 1.
a: the anteroposterior X-ray film of the shoulder joint before operation; b, c: import the image data collected by the O-arm into the robot to plan the screw channel; d, e: under the guidance of the robotic navigation system, one 3.5-mm cannulated screw was inserted; f: the anteroposterior X-ray film of the shoulder joint after operation
Postoperative treatment
All patients were given antibiotic and pain relief treatments after the operation. The affected limb was protected and fixed with a suspension sling. Patients were encouraged to get out of bed and walk early and perform passive activities of the shoulder joint to prevent early adhesion of the shoulder joint. Three weeks after the operation, patients were encouraged to carry out active functional exercises of the shoulder joint (excluding heavy physical activities) when the pain was tolerable, so as to promote the recovery of the range of motion of the shoulder joint and improve muscle strength. In the first three months after the operation, outpatient follow-up and X-ray examination of the scapula were conducted once a month to guide and urge patients to carry out functional exercises; follow-up was conducted once every 3 months after 3 months, and the recovery of shoulder joint function and fracture healing were evaluated comprehensively.
Outcome measures
The operation situations of all patients, such as the operation time and intraoperative blood loss, were recorded. Moreover, the fracture healing time was also truthfully recorded. Fracture healing was defined as the presence of continuous callus on radiographs, absence of local tenderness, and no abnormal mobility at the fracture site. All radiographs were reviewed by two independent observers; discrepancies were resolved by a senior surgeon. During the outpatient follow-up 12 months after the operation, the Constant score was used to evaluate the function of the patients’ shoulder joints [12] (the full score is 100 points, and the higher the score, the better the shoulder joint function), and the VAS pain score (0–10 points, the lower the score, the lighter the pain) was applied to assess the residual pain of the patients’ shoulder joints. Complications were systematically recorded, including neurovascular injury, wound infection, implant loosening, secondary displacement, nonunion, reoperation, and functional deficits.
Results
All patients included in the study completed at least 12 months of follow-up, with an average of 14.2 months, range 12–19 months. The average operation time of the 16 patients was 75.8 min, ranging from 52 to 98 min. The average intraoperative blood loss was 47.3 ml, ranging from 28 to 75 ml. The fractures of all 16 patients healed smoothly, with no nonunion or loss of reduction. The average fracture healing time was 10.2 weeks, ranging from 8 to 14 weeks. One year after the operation, all 16 patients achieved good shoulder joint function. The average Constant score was 90.5 points, ranging from 82 to 97 points. One year after the operation, the average VAS score for the shoulder joints was 1.0 points, ranging from 0 to 4 points. No vascular or nerve injury related to the surgery was found in any patientduring the perioperative period or atfollow-up. The specific information is shown in Table 2.
Table 2.
Intraoperative performance and efficacy indicators
| ID | Follow-up time((months) |
Operation time (min) |
Blood loss (ml) |
Fracture healing time (weeks) |
Constant score |
VAS score |
|---|---|---|---|---|---|---|
| 1 | 16 | 86 | 65 | 10 | 86 | 1 |
| 2 | 14 | 78 | 45 | 9 | 92 | 0 |
| 3 | 16 | 71 | 36 | 12 | 90 | 1 |
| 4 | 12 | 56 | 32 | 9 | 94 | 0 |
| 5 | 12 | 94 | 71 | 11 | 96 | 0 |
| 6 | 12 | 82 | 50 | 14 | 90 | 1 |
| 7 | 14 | 80 | 60 | 10 | 88 | 2 |
| 8 | 18 | 70 | 38 | 10 | 84 | 4 |
| 9 | 12 | 71 | 36 | 9 | 90 | 1 |
| 10 | 13 | 52 | 28 | 8 | 95 | 0 |
| 11 | 15 | 98 | 75 | 13 | 97 | 0 |
| 12 | 19 | 85 | 62 | 10 | 82 | 3 |
| 13 | 14 | 68 | 35 | 9 | 93 | 0 |
| 14 | 17 | 76 | 42 | 11 | 89 | 1 |
| 15 | 12 | 55 | 30 | 8 | 94 | 0 |
| 16 | 15 | 79 | 48 | 10 | 91 | 1 |
Discussion
The coracoid process is the attachment point of the pectoralis minor muscle, the short head of the biceps brachii muscle, and the tendon of the coracobrachialis muscle [13]. At the same time, it is also the origin of the coracoclavicular ligament, coracoacromial ligament, and coracohumeral ligament, playing an important role in maintaining the stability of the anterior and superior part of the shoulder joint. Coracoid process fractures are often accompanied by acromioclavicular joint dislocation or anterior dislocation of the shoulder joint [14]. In the former case, the upward movement of the clavicle and the pulling of the coracoclavicular ligament lead to avulsion fractures of the coracoid process, and the fracture fragments shift upward; in the latter case, the violent contraction and pulling of the combined tendon of the short head of the biceps brachii muscle and the coracobrachialis muscle cause avulsion fractures, and the fracture fragments shift downward. Coracoid process fractures will lead to the destruction of the stability of the suspensory complex of the upper limb and the displacement of the starting and ending points of the ligaments [15].
Eyres classification divides coracoid process fractures into five types based on fracture location and involvement of the scapula or glenoid. [16]. The previous view was that for patients with coracoid process fractures accompanied by dislocation, the dislocation should be preferentially treated, and the coracoid process fracture could be temporarily left untreated [17]. With the continuous development of society, young patients or athletes have high requirements for the function of the shoulder joint [18, 19]. Conservative treatment may lead to pain, nonunion, or limitation of shoulder joint function, and surgical treatment is gradually being chosen more often.
The coracoid process is located relatively deep and is richly covered by muscles. The axillary artery, axillary vein, and brachial plexus nerves pass through the inferomedial side of the base of the coracoid process, and the suprascapular artery and suprascapular nerve pass through the suprascapular notch on the superolateral side of the base. An improper position and direction of the screw may lead to damage to blood vessels and nerves. In traditional surgeries for fixing coracoid process fractures with cannulated screws, it is necessary to repeatedly adjust the entry point and direction of the screw during the operation and verify them through C-arm fluoroscopy. However, for C-arm fluoroscopy, it is necessary to adjust the position to display the long axis of the coracoid process, and limited body positions may increase the difficulty of operation and fluoroscopy. In addition, the instability of the manual screw placement operation may make it difficult to ensure the entry point and direction of the guide pin. Repeated operations may lead to bone loss of the coracoid process, increasing the risks of screw loosening, loss of reduction, and nonunion after the operation. The prolongation of the operation time may also lead to increased bleeding and a higher risk of infection. In this study, we used the O-arm imaging system to assist in the screw placement for coracoid process fractures, which clearly showed the entry point, direction, and depth of the guide pin from a three-dimensional perspective, reduced the number of fluoroscopies, and effectively avoided damaging the blood vessels and nerves around the coracoid process and penetrating the cortical bone.
Compared with traditional surgeries, robot navigation features precise positioning and reduces the exposure time to radiation. It has more obvious advantages, especially in surgeries in high-risk areas and parts with anatomical variations. The O-arm imaging system can provide a local three-dimensional view during the operation [20]. A clear three-dimensional image can be obtained just by performing one fluoroscopy at the surgical site, which enables timely and accurate evaluation of the reduction quality of the coracoid process fracture during the operation. When inserting the screw, it can monitor the direction and depth of the screw in real time to avoid damaging the blood vessels and nerves around the coracoid process and penetrating the cortical bone. When fixing coracoid process fractures with screws in traditional surgeries, it may be necessary to adjust the position of the guide pin multiple times. However, C-arm fluoroscopy is limited by the influence of the body position and the overlapping of the images, making the operation rather difficult. In this study, the use of the robot combined with the O-arm imaging system to assist in the screw fixation of coracoid process fractures of the scapula hardly requires adjusting the position of the guide pin. The surgical process is more intelligent and precise. The positioning and planning of the surgical process are completed according to the computer navigation system, which shortens the learning curve and reduces radiation exposure [21].
The incidence of coracoid process fractures is relatively low, and currently, there is no unified consensus on the surgical treatment plan for coracoid process fractures [22]. Most of the previous studies discussing coracoid process fractures are case reports [19, 23]. The results of our study show that the blood loss ranges from 28 to 75 ml, with an average of 47.3 ml. Compared with a previous study reporting blood loss of 310–530 ml (which used osteotomy), the present study showed markedly less bleeding. [24]. This is because the combination of robot navigation and the O-arm imaging system makes the surgical operation minimally invasive and precise. Although we did not compare the size of the trauma (incision length), the result should be obvious, that is, the trauma caused by the combination of robot navigation and the O-arm imaging system is smaller. A case report proposed that arthroscopic treatment of coracoid process fractures provides a new idea for the minimally invasive treatment of coracoid process fractures. However, the arthroscopic technique itself requires a relatively long learning curve [19]. For doctors who have not mastered the arthroscopic technique, it may be difficult to perform minimally invasive arthroscopic treatment of coracoid process fractures. The robotic workflow is standardized and may be easier to adopt for surgeons without advanced arthroscopic skills. Of course, due to the relatively high cost of the equipment for robot navigation and the O-arm imaging system, and the need for specialized personnel for operation and maintenance, this has limited the dissemination of this technology to a certain extent.
Our study also has some limitations. Firstly, this is a retrospective study. The small sample size and the lack of a control group may lead to certain biases in the research results. Secondly, the follow-up time for the patients included in the study is relatively short, and a longer follow-up period may yield different results. We look forward to conducting large-sample randomized controlled studies in the future to explore the advantages and feasibility of using the robot navigation combined with the O-arm imaging system to assist in the fixation of coracoid process fractures with cannulated screws. Finally, the study cohort included relatively young, high‑demand patients; external validity to older or lower‑demand populations is limited.
Conclusions
In this retrospective case series, robot‑assisted cannulated screw fixation with O‑arm imaging for coracoid process fractures provided satisfactory fracture healing, low complication rates, and good shoulder function at mid‑term follow‑up. The technique enables accurate, minimally invasive placement of screws near neurovascular structures. Given the study’s low level of evidence, further controlled studies are required to confirm comparative benefits, cost‑effectiveness, and long‑term safety.
Acknowledgements
We are extremely grateful to all the patients included in the study and to those who have provided assistance in our clinical work, including all the medical staff in the department dealing with lower limb trauma in the hospital and the operating room staff.
Author contributions
Hongfei Qi, Hua Lin, and Ming Li were responsible for the study design, the definition of intellectual content, and the literature research. Zhong Li and Bo Wu analysed and interpreted the data. Hongfei Qi drafted the manuscript. Kun Zhang, Shuai Ji and Bing Du revised the manuscript. All authors read and approved the final manuscript.
Funding
Supported by the Social Development Project in Shaanxi Province (No. 2025SF-YBXM-089).
Data availability
Not applicable.
Declarations
Ethics approval and consent to participate
This study was performed in agreement with the principles of the Declaration of Helsinki. This study was approved by the ethics committee of Hong Hui Hospital, Xi’an Jiaotong University (Xi’an, Shaanxi, China; 20210923). All patients provided informed consent prior to participation in the study.
Consent for publication
The publication of any individual or any data of any person in this article has been approved by the individual.
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
Not applicable.