Has the arthroscopically assisted reduction of acute AC joint separations with the double tight-rope technique advantages over the clavicular hook plate fixation?

The Diagnosis and Treatment of Acute Dislocation of the Acromioclavicular Joint

BACKGROUND

The acromioclavicular joint (ACJ) is one of the more common sites of shoulder girdle injury, accounting for 4-12% of all such injuries, with an incidence of 3-4 cases per 100 000 persons per year in the general population. Current topics of debate include the proper standard diagnostic evaluation, the indications for surgery, and the best operative method.

METHODS

This review is based on publications retrieved by a selective literature search.

RESULTS

Mechanical trauma of the ACG can tear the ligamentous apparatus that holds the acromion, clavicle, and coracoid process together. Different interventions are indicated depending on the nature of the injury. In recent years, the horizontal component of the instability has received more attention, in addition to its vertical component. Persistent instability can lead to chronic, painful limitation of shoulder function, particularly with respect to working above the head. Surgical stabilization is therefore recommended for high-grade instability of Rockwood types IV and V. Modern reconstruction techniques enable selective vertical and horizontal treatment of the instability and have been found superior to traditional methods, particularly in young athletes. Arthroscopic techniques are advantageous because they are less invasive, do not require removal of implanted material, and afford the opportunity to diagnose any accompanying lesions definitively and to treat them if necessary. Surgery for acute injuries should be performed within three weeks of the trauma. For chronic injuries, additional tendon augmentation is now considered standard treatment.

CONCLUSION

High-grade ACJ instability is a complex and significant injury of the shoulder girdle that can cause persistent pain and functional impairment. The state of the evidence regarding its optimal treatment is weak. Large-scale, prospective, randomized comparative studies are needed in order to define a clear standard of treatment.

Minimally Invasive AC Joint Reconstruction System (MINAR®) in Modified Triple-Button Technique for the Treatment of Acute AC Joint Dislocation

Acute acromioclavicular (AC) joint dislocation is a frequent sports injury with more than 100 different operation methods described. A total of 65 patients with an acute AC joint dislocation were treated with the modified MINAR^® system between 2009 and 2013. Clinical outcome, horizontal and vertical instability, as well as concomitant intraarticular injuries were assessed. We used Zanca, stress and axial X-rays for radiological assessment. A Constant score of 95 (±8.8), University of California Los Angeles Shoulder score (UCLA) of 31 (±4.9), Disabilities of Arm, Shoulder and Hand (DASH) of 9.1 (±14.3), and Visual Analogue Scale (VAS) of 0.9 (±0.126) was found. A total of 30 patients (59%) had no signs of reduction loss, nine patients (18%) a slight loss, 11 patients (22%) a partial loss, and one patient (2%) a total loss. No significant influence on the clinical scores could be shown. The postoperative coracoclavicular (CC) distance negatively affected the Constant (p = 0.007) and UCLA scores (p = 0.035). A longer time interval to surgery had a negative influence on all scores (p ≤ 0.001). We could not find any signs of persistent horizontal instability or intraarticular injuries at follow-up. The MINAR^® system promises satisfactory functional and radiological results. When setting the correct indication, patients benefit from an early operation. No persisting horizontal instability was observed following suturing of the AC capsule and the delta fascia.

Anatomic ligament consolidation of the superior acromioclavicular ligament and the coracoclavicular ligament complex after acute arthroscopically assisted double coracoclavicular bundle stabilization

PURPOSE

The consolidation of the acromioclavicular (AC) and coracoclavicular (CC) ligament complex after arthroscopically assisted stabilization of acute acromioclavicular joint (ACJ) separation is still under consideration.

METHODS

Fifty-five consecutive patients after arthroscopically assisted double-CC-bundle stabilization within 14 days after acute high-grade ACJ separation were studied prospectively. All patients were clinically analysed preoperatively (FU0) and post-operatively (FU1 = 6 months; FU2 = 12 months). The structural MRI assessments were performed at FU0 (injured ACJ) and at FU2 bilateral (radiologic control group) and assessed separately the ligament thickness and length at defined regions for the conoid, trapezoid and the superior AC ligament.

RESULTS

Thirty-seven patients were assessed after 6.5 months and after 16.0 months. The 16-month MRI analysis revealed for all patients continuous ligament healing for the CC-complex and the superior AC ligament with in the average hypertrophic consolidation compared to the control side. Separate conoid and trapezoid strands (double-strand configuration) were detected in 27 of 37 (73%) patients, and a single-strand configuration was detected in 10 of 37 (27%) patients; both configurations showed similar CCD data. The ligament healing was not influenced by the point of surgery, age at surgery and heterotopic ossification. The clinical outcome was increased (FU0-FU2): Rowe, 47.7-97.0 pts.; TAFT, 3.9-10.6 pts.; NAS _pain, 8.9-1.4 pts. (all P < 0.05).

CONCLUSION

The arthroscopically assisted double-CC-bundle stabilization within 14 days after acute high-grade ACJ separation showed 16 months after surgery sufficient consolidations of the AC and double-CC ligament complex in 73%.

LEVEL OF EVIDENCE

III, Case series.

Outcome of arthroscopy-assisted treatment for distal clavicle fractures

HYPOTHESIS

The purpose of the present study was described as the arthroscopically assisted procedure that uses a synthetic conoid ligament reconstruction using Zip Tight (Zimmer biomet, Warsaw, USA) and fracture-site fixation with K-wire. Our hypothesis was that this technique provided a satisfactory functional outcome with minimum complication.

METHODS

45 patients underwent operation to treat fractures of the distal clavicle between January 2014 and May 2017. The inclusion criteria were as follows: (1) there is an episode of trauma and it is the first fracture (2) distal clavicle fracture of Neer type IIb with dislocation in image findings. The exclusion criteria were as follows: (1) Neer type I, IIa and III of distal clavicle fracture (2) existing injury of rotator cuff, biceps tendon and labral during the arthroscopic procedure. Based on these criteria, 23 patients were included in this study. Clinical outcome assessments were performed using 1-year postoperative Quick DASH score, Constant-Murley score, ASES score. Radiological outcome consisted of antero-posterior and axillary radiographs.

RESULTS

Mean clinical outcomes were as follows: Quick DASH score was 3.8 ± 2.8, ASES score was 92.3 ± 3.2 and Constant-Murley score was 94.1 ± 3.0. It was a highly satisfactory result in all of the score at 1-year follow-up. All patients had achieved radiographic union at a minimum 1-year follow-up. There were no cases of nonunion or osteolysis.

CONCLUSIONS

This study demonstrated that the arthroscopy-assisted treatment using Zip Tight and K-wire provided a satisfactory functional outcome with minimum complication with Neer type IIb fractures of the distal clavicle.

LEVEL OF EVIDENCE

IV, Case series, Treatment study.

Acromioclavicular joint disruptions: A comparison of two surgical approaches 'hook' and 'rope'

INTRODUCTION

Acromioclavicular joint injuries are common shoulder girdle injuries most commonly resulting from a direct blow to the acromion with the arm adducted. Type-I or type-II acromioclavicular joint injuries can be managed with sling immobilization, early shoulder motion, and physiotherapy. The management of type-III injuries remains controversial and is individualized. Type IV and V injuries should be treated surgically. A myriad of surgical techniques for the management of acromioclavicular joint injuries have been reported.

METHODS

We present a comparative study of 76 patients treated with two most common modalities of treatment for AC joint disruption and that is Hook plate stabilisation (n=52) or arthroscopically assisted tight rope stabilisation (n=24). The primary objective was to establish whether hook plate stabilization was superior compared to arthroscopic tight rope fixation in reducing pain and increasing function in the short-term and long-term for patients with AC joint disruptions III-IV. We also wanted to assess how quickly patients returned to their work/job. It was a prospective study, we included all the patients operated between 2008 and 2015 for AC joint disruption by the two shoulder surgeons of our department. All patients followed a strict physiotherapy protocol and were assessed at 6 weeks, 3 months and 12 months. We used the Harm and cost criteria of assessment and the patient specific functional outcome scores.

RESULTS

Both modalities of treatment have high patient satisfaction rate, return to work is faster in tight rope group but after a year both group of patients returned to their premorbid state. Removal of hook plate is not mandatory and lysis of acromion is rare (1% in our series).

CONCLUSION

Despite the fact that both methods yielded similar results and have statistically similar number of complications, the type of postoperative complications was different between groups. The plate group had more postoperative pain and worse function but both aspects improved after plate removal. The rope group had more complex complications including deep infection and recurrence of deformity and fracture. These differences should be taken into consideration when consenting the patient regarding possible treatment.

Acromioclavicular joint injuries in overhead athletes: a concise review of injury mechanisms, treatment options, and outcomes

PURPOSE OF THE REVIEW

To review the relevant literature surrounding acromioclavicular (AC) joint injuries particularly pertaining to overhead athletes.

RECENT FINDINGS

The AC joint is a unique anatomic and biomechanical portion of the shoulder that can be problematic for athletes, particularly throwers, when injured. Treatment of these injuries remains a topic in evolution. Low-grade injuries (Rockwood types I & II) are typically treated non-operatively while high-grade injuries (types IV, V, and VI) are considered unstable and often require operative intervention. Type III AC separations remain the most controversial and challenging as no clear treatment algorithm has been established. A wide variety of surgical techniques exist. Unfortunately, relatively little literature exists with regard to overhead athletes specifically. Treatment of AC joint injuries remains challenging, at times, particularly for overhead athletes. Operative indications and techniques are still evolving, and more research is needed specifically surrounding overhead athletes.

All-Arthroscopic Reconstruction of Severe Chronic Acromioclavicular Joint Dislocations

PURPOSE

To report the outcomes of all-arthroscopic coracoclavicular (CC) ligament reconstruction and simultaneous diagnosis and treatment of glenohumeral pathologies in patients with symptomatic, chronic (>6 weeks), complete (Rockwood type III-V) acromioclavicular joint (ACJ) separations.

METHODS

We prospectively followed up 57 consecutive patients treated arthroscopically for chronic Rockwood type III (n = 11), type IV (n = 19), and type V (n = 27) ACJ dislocations. Previous ACJ surgery failed in 11 (19%). The mean delay between injury and surgery was 39 months (range, 6 months to 17 years). The mean age at surgery was 42 years (range, 19-71 years). After glenohumeral exploration, an arthroscopic modified Weaver-Dunn procedure with CC suture button fixation (Twinbridge) was performed. The CC reduction and tunnel position were analyzed with radiographs and computed tomography. The mean follow-up period was 36 months (range, 12-72 months).

RESULTS

Intra-articular pathology was treated arthroscopically in 27 patients (48%): 17 labral tears, 8 rotator cuff tears (3 partial and 5 complete), and 15 biceps lesions (4 SLAP lesions and 11 subluxations). At last follow-up, 7 patients (12%) experienced recurrent ACJ instability: 2 frank dislocations (1 trauma and 1 infection) and 5 ACJ subluxations. There was no significant correlation between subluxation and clinical outcome. The rate of recurrent ACJ instability was significantly higher in patients with higher-grade ACJ dislocations (P < .01) and/or previous failed surgery (P < .001). Recurrent subluxation was observed in 3 cases of lateral migration of the coracoid button with lateral tunnel placement, as well as 2 cases of anterior migration of the clavicular button with anterior tunnel placement. The Constant score increased from 67 (range, 28-89) to 85.5 (range, 66-100), and the mean Subjective Shoulder Value increased from 54% to 85% (P < .001). At last follow-up, 95% of patients (54 of 57) were satisfied.

CONCLUSIONS

All-arthroscopic treatment allows successful CC ligament reconstruction and simultaneous diagnosis and treatment of frequently associated (48%) glenohumeral lesions. Higher-grade ACJ dislocations, previous ACJ surgery, and misplacement of bone tunnels are risk factors for recurrent instability.

LEVEL OF EVIDENCE

Level IV, case series.

Clinical outcomes of arthroscopic assissted fixation of acute high grade acromioclavicular joint disruption

Background

Management of high grade acute acromioclavicular (AC) joint dislocation is considered a surgical dilemma. Open methods of fixation are the gold standard but the morbidities are frequent. The goal of this study was to evaluate the results of arthroscopic fixation of acute high grade (AC) joint dislocation.

Methods

A series of 24 patients with acute high grade acromioclavicular joint dislocation were fixed arthroscopically using TightRope device. The study was done between February 2013 and February 2017. The functional outcomes were assessed using Constant-Murley score and University of California at Los Angeles shoulder (UCLA) scale. The preoperative and postoperative means of coraco-clavicular distance were calculated and used for radiological assessment. P-value < o.o5 was statistically significant.

Results

The mean followed up time was 23.25 ± 7.1 (12-35) months. There was highly significant improvement in the Constant-Murley score and (UCLA) scale at the end of the follow up period. The coraco-clavicular distance was improved from 21.7 ± 3.1 mm preoperative to 10.17 ± 2.3 mm postoperative. There were two complications, one case had over correction and the other had mild transient post-operative burning pain along the course of ulnar nerve.

Conclusion

Arthroscopic fixation of acute high grade (AC) joint dislocation is safe, minimally invasive technique with satisfactory functional outcomes and low morbidities provided that it is done by surgeons skilled in shoulder arthroscopy.

Fifteen-degree clavicular hook plate achieves better clinical outcomes in the treatment of acromioclavicular joint dislocation

OBJECTIVE

Clavicular hook plate application is one of the most commonly used treatment methods for acromioclavicular (AC) joint dislocation, although it may cause multiple postoperative complications. We modified the regularly used 0° hook plate to 15° and compared the clinical outcomes of these two hook plates for treatment of AC joint dislocation.

METHODS

Forty-three patients with acute AC joint dislocation were randomly enrolled (0° hook plate, 20 patients; 15° hook plate, 23 patients). The American Shoulder and Elbow Surgeons (ASES) and visual analog scale for pain (VASP) scores were evaluated preoperatively and at 3 days and 1, 2, 3, and 6 months postoperatively and compared between the two groups.

RESULTS

Compared with the preoperative scores, the 6-month postoperative ASES score gradually increased but the VASP score decreased in both groups. Furthermore, the ASES and VASP scores were significantly different between the two groups at every postoperative time point.

CONCLUSION

The 15° hook plate is superior to the 0° hook plate in reducing shoulder pain and improving postoperative recovery in the treatment of AC joint dislocation.

LEVEL OF EVIDENCE

Level III; Treatment study (retrospective comparative study).

Arthroscopic Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Dislocation

BACKGROUND

The purpose of this study was to evaluate mid- and long-term clinical and radiologic outcomes of arthroscopic coracoclavicular ligament reconstruction (ACCLR) with an artificial ligament for acute dislocation of the acromioclavicular joint (ACJ).

METHODS

Twelve male patients (average age at the time of surgery: 40.8 years, range: 21-64 years) underwent ACCLR with an artificial ligament for acute dislocation of the ACJ type III or type V according to the Rockwood classification. Arthroscopic surgery was performed with the patient under general anesthesia and interscalene brachial plexus block in the beach-chair position. Reduction of the ACJ was performed manually or using an elevator under control of an imaging intensifier. The ACJ was fixed temporarily with a Kirschner wire. Bone tunnels of the coracoid process and clavicle were made with a cannulated drill. An artificial ligament was pulled out through the bone tunnels and fixed on the upper surface of the clavicle with a staple and interference screw, and on the undersurface of the coracoid process with an Endobutton. The shoulder was immobilized with a shoulder brace for 4 weeks postoperatively, and rehabilitation was started in the first postoperative week. The Japan Shoulder Society Acromioclavicular Joint Function Assessment (JSS-ACJ) score was used for evaluation of clinical outcomes, and plain radiographs were performed after a minimum follow-up period of 5 years postoperatively.

RESULTS

The average follow-up period after surgery was 106.3 months (range: 62-128 months). The average postoperative JSS-ACJ score was 97.2 points (range: 92-100). The seven patients who had been playing sports before injury all returned to their pre-injury level. No patients complained of pain or shoulder dysfunction in daily activities, work, or sports. There were no complications such as neurovascular injuries during surgery, infection, or foreign body reaction from the artificial ligament. Radiographs at the final follow-up showed subluxation of the ACJ and non-symptomatic osteoarthritic changes of the ACJ in two patients, respectively.

CONCLUSION

ACCLR for acute dislocation of the ACJ is a useful surgical procedure that gives satisfactory clinical and radiologic outcomes on mid- and long-term follow-up. ACCLR can stabilize vertical instability of the ACJ. If instability in the horizontal direction remains, repair or reconstruction of the acromioclavicular ligament should be added to prevent osteoarthritic changes of the ACJ.

Percutaneous minimally invasive repair of acromioclavicular joint dislocation using cannulated screws under ultrasonic vs. C-arm navigation: A prospective trial

INTRODUCTION

To compare percutaneous minimally invasive repair (PMIR) of acute acromioclavicular (AC) joint dislocation under ultrasound guidance (PMIR-UN) vs. C-arm navigation (PMIR-CN).

HYPOTHESIS

PMIR-UN has similar functional and radiographic outcomes as PMIR-CN.

MATERIALS AND METHODS

We treated 48 patients with acute grade III or V AC joint dislocation with surgical reduction and fixation with Kirschner wires and cannulated screws. The patients were randomly divided into a PMIR-UN group (n=24) and a PMIR-CN group (n=24). We assessed functional outcomes, operative duration, incision length, and intraoperative radiation exposure. Shoulder joint function was evaluated with the Constant-Murley score, and postoperative efficacy was evaluated using the Karlsson criteria.

RESULTS

The median follow-up duration was 13 months (range, 8-18 months). Satisfactory functional outcomes were obtained in both groups. Incision length, incidence of postoperative infection, pin migration, and postoperative efficacy did not differ between the two groups. Operative duration and intraoperative radiation dose were significantly greater in the PMIR-CN group than in the PMIR-UN group (P<0.05). Kirschner wires were removed at 4 weeks after surgery, and cannulated screws were removed at 12 weeks after surgery in both groups.

DISCUSSION

Based on the satisfactory results obtained in all patients, we conclude that PMIR-UN is a safe, easy, and reliable technique for the treatment of acute grade III or V AC joint dislocation.

TYPE OF STUDY

Low-powered prospective randomized trial.

LEVEL OF EVIDENCE

Level II.

Are Hook Plate Complications Inevitable?

No abstract available.

Comparison of surgical and conservative treatment of Rockwood type-III acromioclavicular dislocation: A meta-analysis

BACKGROUND

There is no consensus on the effects of surgical versus conservative treatment on Rockwood type-III dislocation of the acromioclavicular joint in general orthopedic practice. The objective of this meta-analysis was to compare the clinical outcomes of patients managed surgically and conservatively following type-III acromioclavicular (AC) dislocation.

METHODS

The Cochrane Library, EMBASE, MEDLINE via Ovid SP, and PubMed databases were searched for randomized controlled trials and observational studies. Patient data were pooled using standard meta-analytic approaches. For continuous variables, the weighted mean difference was used. For dichotomous data, the odds ratio was calculated.

RESULTS

The current analysis included 10 trials on this topic, and the results demonstrated that there were no significant differences between surgical and conservative treatment in terms of pain, weakness, tenderness, post-traumatic arthritis, restriction of strength, unsatisfactory function, and scores (Constant, UCLA, Imatani, SST, DASH, Larsen). Analyses of ossification of the coracoclavicular ligament (OR = 1.62, 95% CI = 1.01-2.61) and osteolysis of the lateral clavicle (OR = 2.87, 95% CI = 1.27-6.52) suggested better function with conservative treatment versus surgical treatment, but the latter was superior to conservative treatment with regard to loss of anatomic reduction. Only 1 study showed a higher acromioclavicular joint instability score for surgical management compared with conservative management (P < .00001).

CONCLUSION

In the management of Rockwood type-III AC dislocation, conservative treatment is superior to surgical treatment. Nonoperative treatment results in a lower incidence of ossification of the coracoclavicular ligament and osteolysis of the lateral clavicle compared with operative treatment. However, there was no statistical difference between operative and nonoperative treatment in terms of clinical outcomes.

Combined arthroscopically assisted coraco- and acromioclavicular stabilization of acute high-grade acromioclavicular joint separations

PURPOSE AND HYPOTHESIS

Due to high rate of persisting dynamic posterior translation (DPT) following isolated coracoclavicular double-button technique for reconstruction of the acromioclavicular (AC) joint reported in the literature, an additional acromioclavicular cerclage was added to the procedure. The aim of this study was to evaluate the clinical and radiological results of patients with high-grade AC-joint instability treated with a double TightRope technique with an additional percutaneous acromioclavicular cerclage.

METHODS

Fifty-nine patients (6 f/53 m; median age 38.3 (range 21.5-63.4 years) who sustained an acute high-grade AC-joint dislocation (Rockwood type V) were treated using the above-mentioned technique. At the final follow-up, the constant score (CS), the subjective shoulder value (SSV), the Taft score (TF) and the acromioclavicular joint instability score (ACJI) as well as bilateral anteroposterior stress views with 10 kg of axial load and bilateral modified Alexander views were obtained.

RESULTS

At a median follow-up of 26.4 (range 20.3-61.0) months, 34 patients scored a median of 90 (33-100) points in the CS, 90 (25-100) % in the SSV, 11 (4-12) points in the TF and 87 (43-100) points in the ACJI. The coracoclavicular (CC) distance was 12.1 (6.5-19.8) mm and the CC difference 2.0 (0.0-11.0) mm. Two patients (5.8%) showed a complete DPT of the AC joint, and fourteen patients (41.1%) displayed a partial DPT. The overall revision rate was 11.7%. Two patients presented implant irritation, one patient a recurrent instability, and one patient suffered from a local infection.

CONCLUSION

The arthroscopically assisted and image-intensifier-controlled double TightRope technique with an additional percutaneous acromioclavicular cerclage leads to good and excellent clinical results after a follow-up of 2 years. The incidence of persisting dynamic horizontal translation is lower compared to isolated coracoclavicular stabilization. Thus, we recommend using the double TightRope implant with an additional acromioclavicular cerclage.

LEVEL OF EVIDENCE

IV.

New insights in the treatment of acromioclavicular separation

A direct force on the superior aspect of the shoulder may cause acromioclavicular (AC) dislocation or separation. Severe dislocations can lead to chronic impairment, especially in the athlete and high-demand manual laborer. The dislocation is classified according to Rockwood. Types I and II are treated nonoperatively, while types IV, V and VI are generally treated operatively. Controversy exists regarding the optimal treatment of type III dislocations in the high-demand patient. Recent evidence suggests that these should be treated nonoperatively initially. Classic surgical techniques were associated with high complication rates, including recurrent dislocations and hardware breakage. In recent years, many new techniques have been introduced in order to improve the outcomes. Arthroscopic reconstruction or repair techniques have promising short-term results. This article aims to provide a current concepts review on the treatment of AC dislocations with emphasis on recent developments.

Short-term outcomes of arthroscopic TightRope® fixation are better than hook plate fixation in acute unstable acromioclavicular joint dislocations

AIM

The aim of this study was to compare the short-term outcomes of arthroscopic TightRope^® fixation with that of hook plate fixation in patients with acute unstable acromioclavicular joint dislocations.

PATIENTS AND METHODS

We conducted a prospective case-control study of twenty-six patients with an acute ACJ dislocation who underwent surgical repair with either an arthroscopic TightRope^® fixation or a hook plate from 2013 to 2016. Clinical and radiological data were collected prospectively. Clinical outcomes were evaluated using the Constant Score, the University of California at Los Angeles (UCLA) Shoulder Score, Oxford Shoulder Score as well as the visual analogue scale. Radiological outcomes were assessed with the coracoclavicular distance (CCD).

RESULTS

Sixteen patients underwent arthroscopic TightRope^® fixation, while 10 patients underwent hook plate fixation. There were no significant differences in the preoperative variables except for the mean UCLA 4b infraspinatus score (TightRope^® 2.8 vs. hook plate 3.8; p = 0.030). Duration of surgery was significantly longer in the TightRope^® group. At 1 year post-operatively, the TightRope^® group had a significantly better Constant Score and CCD with no complications. All patients with hook plate fixation had to undergo a second procedure for removal of implant, and 3 patients had complications.

CONCLUSIONS

Arthroscopic TightRope^® fixation is a good option for the treatment of acute unstable ACJ dislocations. It has better short-term clinical and radiological outcomes as well as lesser complications when compared to hook plate fixation.

LEVEL OF EVIDENCE

Therapeutic, Level III.

A comparison between two double-button endoscopically assisted surgical techniques for the treatment acute acromioclavicular dislocations

PURPOSE

To compare clinical and radiological outcomes between two endoscopically assisted double-button techniques in high-grade acute acromioclavicular separations.

METHODS

A retrospective single-center study was conducted in patients with acute acromioclavicular joint dislocation Rockwood types III and V, from 2009 to 2014. All were treated endoscopically, with a 1-year minimum follow-up. Two consecutive series were conducted; the first (TR group) received the TightRope^® system, whereas last series (DB group) was treated with the Dog Bone^® button technology (Arthrex, Naples, FL, USA). Primary endpoints were last follow-up values of Constant score (CS) and Quick-DASH (QD) score. Moreover, the posttraumatic displacement and its evolution were assessed on bilateral Zanca radiographs. A displacement of 5 mm or greater the day after surgery was considered as a lack of reduction; the same difference on last follow-up X-rays was considered as a loss of reduction.

RESULTS

Forty patients were reviewed: 22 in the TR group and 18 in the DB group. After a mean follow-up of 27.7 ± 8.3 months, CS and QD averaged, respectively, 94.3 ± 4.4 and 2.0 ± 2.6 in the TR series, whereas they averaged, respectively, 95 ± 6.1 and 3.4 ± 3.3 in the DB series after a mean follow-up of 24.1 ± 5 months (PCS = 0.16, PQDS = 0.08). Lack of reduction and loss of reduction rates were significantly higher in the DB group, with P = 0.0005 and P < 0.0001, respectively.

CONCLUSIONS

Both techniques provided good to excellent functional outcomes. However, considering inferior radiological results using the Dog Bone^® device, we would prefer the TightRope^® device in acute acromioclavicular dislocations.

LEVEL OF EVIDENCE

IV: Therapeutic study-cases series.

Open capsular and ligament reconstruction with semitendinosus hamstring autograft successfully controls superior and posterior translation for type V acromioclavicular joint dislocation

PURPOSE

Appropriate surgical management for type V complete acromioclavicular (AC) joint dislocation remains controversial. The purpose of this paper is to retrospectively report the clinical and radiographic outcomes of an open surgical technique consisting for AC joint ligamentous and capsular reconstruction using autologous hamstring tendon grafts and semi-permanent sutures.

METHODS

Between January 2005 and December 2011, 32 consecutive patients with symptomatic type V complete AC joint dislocation underwent surgical treatment using the same technique. The median time from injury to surgery was 45 days (range 24-90). The average median postoperative clinical and radiographic follow-up time was 30 months (range 24-33). Clinical outcomes measures included the ASES score, the visual analog score (VAS), and subjective patient satisfaction score. Minimum follow-up was 2 years.

RESULTS

ASES score increased from a median of 38.2 ± 6.2 preoperative to 92.1 ± 4.7 postoperatively (p ≤ 0.05). The median VAS score improved from 62 mm (range 45-100 mm) preoperatively to 8 mm (range 0-20 mm) at final follow-up (p ≤ 0.05). No patient experienced pain or discomfort with either direct palpation of the AC joint or with cross-body adduction. Final radiographs demonstrated symmetric AC joint contour in 25/32 (78%) patients. Seven patients (22%) radiographically demonstrated superior translation of the distal clavicle relative to the superior margin of the acromion but less than 50% of the clavicular width. 30/32 patients (93%) were able to return to their pre-injury level of work and sports activities.

CONCLUSIONS

This novel surgical technique using a free graft and braided suture for simultaneous coracoclavicular ligament and AC joint capsular reconstruction successfully controls superior and posterior translations after type V AC joint dislocation and minimizes the incidence of persistent postoperative AC joint subluxation.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Early complications of acromioclavicular joint reconstruction requiring reoperation

PURPOSE

Prior studies have reported high complication rates with acromioclavicular joint reconstruction (ACJR). However, many of these reports have suffered from small sample sizes and inclusion of older surgical techniques. The purpose of this study was to determine the rates of early complications requiring reoperation in patients treated with ACJR.

METHODS

From 2007 to 2011, patients who were treated with ACJR were identified using the PearlDiver database, a large insurance database in the USA. The following reoperations were then queried from this patient cohort: irrigation and debridement within 30 days of index surgery, manipulation under anaesthesia (MUA) of the shoulder joint within 3 months of index surgery, and revision ACJR, distal clavicle excision, and removal of hardware within 6 months of index surgery.

RESULTS

In total, 2106 patients treated with ACJR were identified. The reoperation rates for irrigation and debridement, MUA, revision ACJR, distal clavicle excision, and removal of hardware were 2.6, 1.3, 4.2, 2.8, and 6.2 %, respectively. Patients ≥35 years of age and females more likely to undergo a reoperation after ACJR. Specifically, patients ≥35 years of age were more likely to undergo MUA and revision ACJR, while patients ≥50 years of age were more likely to undergo an irrigation and debridement. Females were more likely than males to undergo revision ACJR and distal clavicle excision.

CONCLUSIONS

Older patients and females were more likely to experience postoperative complications requiring reoperations, including revision ACJR, distal clavicle excision, and irrigation and debridement. By analysing a large cohort of patients across multiple centres and providers, this study provides valuable insight into the recent complication profiles of ACJR, allowing surgeons to appropriately counsel patients on the risks of these procedures.

LEVEL OF EVIDENCE

IV.

Acromioclavicular joint dislocations: coracoclavicular reconstruction with and without additional direct acromioclavicular repair

PURPOSE

To evaluate different stabilisation techniques for acromioclavicular (AC) joint separations, including direct AC repair, and to compare the properties of the stabilised and native joints.

METHODS

An established in vitro testing model for the AC joint was used to analyse joint stability after surgical reconstruction [double TightRope (DTR), DTR with AC repair (DTR + AC), single TR with AC repair (TR + AC), and PDS sling with AC repair (PDS + AC)]. Twenty-four human cadaveric shoulders were randomised by age into four testing groups. Joint stiffness was measured by applying an axial load during defined physiological ranges of motion. Similar tests were performed for the native joints, after dissecting the coracoclavicular and AC ligaments, and after surgical reconstruction. Cyclic loading was performed for 1000 cycles with 20-70 N and vertical load to failure determined after cyclic testing.

RESULTS

Axial stiffness for all TR groups was significantly higher than for the native joint (DTR 38.94 N/mm, p = 0.005; DTR + AC 37.79 N/mm, p = 0.015; TR + AC 45.61 N/mm, p < 0.001 vs. native 26.05 N/mm). The axial stiffness of the PDS + AC group was similar to that of the native joint group (21.4 N/mm, n.s.). AC repair did not significantly influence rotational stiffness. Load to failure was similar and >600 N in all groups (n.s.).

CONCLUSION

Reconstruction of AC dislocations with one or two TRs leads to stable results with a higher stiffness than the native joints. For the PDS + AC group, axial stiffness was similar to the native situation, although there might be a risk of elongation. Direct AC repair showed no significantly increased stability in comparison with reconstructions without direct AC repair. Thus, a direct AC repair seems to be dispensable in clinical practice, while TRs or PDS cerclages appear to provide sufficiently stable results.

Sports activity after anatomic acromioclavicular joint stabilisation with flip-button technique

PURPOSE

Sports activity after surgical AC joint stabilisation has not been comprehensively evaluated to date. The aim of this study was to determine rate, level and time to return to sports after AC joint stabilisation and to identify the influence of overhead sports on post-operative sports activity.

METHODS

In this retrospective case series, a total of 68 patients with a high-grade AC joint dislocation (Rockwood type V) were stabilised using a single TightRope technique. Fifty-five patients (80.9 %) with median age of 42.0 (range, 18-65) years completed questionnaires regarding sports activity before and after surgery. Clinical outcome and complications were also evaluated. Forty-three patients participated in sports regularly before injury. Their sports activity was rated according to Allain, and non-overhead and overhead sports were differentiated.

RESULTS

At median follow-up of 24 (18-45) months, 41 of 43 patients (95.3 %) had returned to sports. 63 % returned to the same sports activity as before injury. 16.3 % needed to adapt the type of sports to reduce demanding activities. 11.6 % reduced the frequency and 32.5 % the intensity of sports. The median time to return to sports was 9.5 (3-18) months. Overhead athletes (Allain Type III and IV) had to reduce their sports activity significantly more often (11.8 vs. 53.8 %; p = 0.011) and needed more time to return to sports (9.5 vs. 4.5 months; p = 0.009).

CONCLUSION

After stabilisation of AC joint dislocation, the majority of patients returned to sports after a substantial period of time. Overhead athletes, in particular, required more time and had to considerably reduce their sports activity. The findings impact therapeutic decision-making after AC joint injury and help with the prognosis and assessment of rehabilitation progress.

LEVEL OF EVIDENCE

IV.

Concomitant glenohumeral pathologies associated with acute and chronic grade III and grade V acromioclavicular joint injuries

PURPOSE

The purpose of this study was to identify the risk of concomitant glenohumeral pathologies with acromioclavicular joint injuries grade III and V.

METHODS

Patients who underwent arthroscopically-assisted stabilization of acromioclavicular joint injuries grade III or grade V between 01/2007 and 12/2015 were identified in the patient databases of two surgical centres. Gender, age at index surgery, grade of acromioclavicular joint injury (Rockwood III or Rockwood V), and duration between injury and index surgery (classified as acute or chronic) were of interest. Concomitant glenohumeral pathologies were noted and their treatment was classified as debridement or reconstructive procedure.

RESULTS

A total of 376 patients (336 male, 40 female) were included. Mean age at time of arthroscopic acromioclavicular joint reconstruction surgery was 42.1 ± 14.0 years. Overall, 201 patients (53%) had one or more concomitant glenohumeral pathologies. Lesions of the biceps tendon complex and rotator cuff were the most common. Forty-five patients (12.0%) had concomitant glenohumeral pathologies that required an additional repair. The remaining 156 patients (41.5%) received a debridement of their concomitant pathologies. Rockwood grade V compared to Rockwood grade III (p = 0.013; odds ratio 1.7), and chronic compared to acute injury were significantly associated with having a concomitant glenohumeral pathology (p = 0.019; odds ratio 1.7). The probability of having a concomitant glenohumeral pathology was also significantly associated with increasing age (p < 0.0001).

CONCLUSIONS

Concomitant glenohumeral pathologies were observed in 53% of surgically treated patients with an acute or chronic acromioclavicular joint injury of either grade III or V. Twenty-two percent of these patients with concomitant glenohumeral pathologies received an additional dedicated repair procedure. Although a significant difference in occurrence of concomitant glenohumeral pathologies was seen between Rockwood grades III and V, and between acute and chronic lesions, increasing age was identified as the most dominant predictor.

LEVEL OF EVIDENCE

Level IV, case series.

Comparative study on the treatment of Rockwood type III acute acromioclavicular dislocation: Clinical results from the TightRope® technique vs. K-wire fixation

BACKGROUND AND HYPOTHESIS

The aim of this study was to address the inconsistency regarding the operative treatment of Rockwood type III acromioclavicular joint separation. We compared results after single- and double TightRope^® reduction with results after acromioclavicular transfixation via K-wires only and additional ligament augmentation in acute acromioclavicular (AC) joint separations graded Rockwood type III, and hypothesized that the TightRope^® technique leads to better clinical and radiological results.

MATERIALS AND METHODS

We conducted a retrospective clinical cohort study and included 42 consecutive patients (mean age 43 years [24-66]) diagnosed and operatively treated between 2004 and 2012 (mean follow-up was 54.6 months [15-118]). Specific shoulder scores as well as scores reflecting the patients' overall mental and physical health status were used. Radiological evaluation was also performed.

RESULTS

The SF12 test revealed comparability between all subgroups. Specific shoulder tests and a visual analogue scale demonstrated comparable results. Radiographic measurements showed a significant reduction in the AC distance and CC distance after surgery in all subgroups. The early complication rate was 9.5% for all patients, while late complications occurred in 14.3% of all cases.

CONCLUSIONS

Compared to the established methods, the operative TightRope^® procedures represent a safe alternative in Rockwood III injuries. All investigated techniques predominantly led to good and excellent clinical results in acute Rockwood type III AC joint instabilities. Avoidance of material removal and shorter hospital stays appear to speak in favour for the TightRope^® technique.

LEVEL OF EVIDENCE

IV.

Arthroscopic Reconstruction After Acute Acromioclavicular Separation Injuries

Acute acromioclavicular (AC)-joint dislocations are common injuries of the shoulder girdle. Surgical repair is indicated for acute high-grade (Rockwood types IV, V, and VI) AC-joint injuries. The best treatment for type III is still controversial, but young and active patients with this type of injury might benefit from a surgical AC-joint stabilization. Surgery should be performed within the first 3 weeks after the injury since the biological healing potential decreases with time. Acute AC-joint separation is diagnosed by clinical examination and radiography. Vertical translation anteroposterior stress views with a 10-kg load are used to grade the injuries. Bilateral lateral stress (Alexander) views are used to evaluate dynamic horizontal translation qualitatively. Arthroscopic techniques for AC reconstruction have become more popular in recent years because they are minimally invasive; they allow treatment of concomitant glenohumeral lesions; and they can be performed in one step, with insertion of implants that do not have to be removed later. The arthroscopically assisted double-button technique with an additional AC cerclage was developed to stabilize the AC joint by internal bracing of the torn ligaments. The procedure consists of the following steps. Step 1: With the patient in the beach-chair position, a 2-cm incision is made on top of the clavicle and posterior and lateral viewing portals as well as an anteroinferior working portal are created. Step 2: With the arthroscope in the lateral portal, the subcoracoid bursa and the base of the coracoid are dissected with a radiofrequency ablation device through the anteroinferior portal. Step 3: Coracoclavicular drilling is done with use of a drill guide and under arthroscopic and image-intensifier control. After overdrilling of the Kirschner wires, Nitinol suture passers are introduced and retrieved via the anteroinferior portal. Step 4: Transclavicular and transacromial drill-holes are established for the AC cerclage. Step 5: The 2 double-button devices are attached to the Nitinol suture passers, and the inferior buttons are shuttled through the clavicle and coracoid and then placed parallel to the coracoid base. Step 6: The sutures are tightened, and an anatomical vertical reduction of the AC joint is achieved. Step 7: A triangular acromioclavicular nonabsorbable cerclage tape is used for horizontal stabilization. Step 8: The clavicular incision is closed in 2 layers, including the repair of the deltotrapezoidal fascia and the arthroscopic portals, in a standard fashion. The combined arthroscopically-assisted and image-intensifier-controlled double-button technique with an additional AC cerclage is a safe procedure that enables an anatomical reduction of the AC joint and yields good to excellent clinical results.

Post-operative outcomes and complications of suspensory loop fixation device versus hook plate in acute unstable acromioclavicular joint dislocation: a systematic review and meta-analysis

BACKGROUND

Treatment of acute (≤3 weeks) acromioclavicular joint dislocation type III-VI is still controversial. Currently, the two modern techniques that are widely used are hook plate (HP) fixation and coracoclavicular ligament fixation using a suspensory loop device that consists of either a tightrope (single or double), endo-button (single or double), or synthetic ligament and absorbable polydioxansulfate sling.

MATERIALS AND METHODS

This systematic review was conducted according to the PRISMA guidelines. Relevant studies that reported Constant-Murley score (CMS), Pain Visual Analog score (VAS) and postoperative complications of either technique were identified from Medline and Scopus from inception to 5 October 2015.

RESULTS

Sixteen studies were included for the analysis of HP fixation, and 25 studies were included for analysis of loop suspensory fixation (LSF). Pooling of mean CMS and VAS scores gave 90.35 (95% CI 87.16, 93.54), 1.51 (95% CI 0.73, 2) in the HP group, and 92.48 (95% CI 90.91, 94.05), 0.32 (95% CI 0, 0.64) in the suspensory loop devices group, respectively. The pooled unstandardized mean differences (UMD) scores of CMS and VAS in LSF were 2.13 (95% CI -1.43, 5.69) and -1.19 (95% CI -2.03, -0.35) when compared to hook plating. The pooled prevalence of LSF and hook plating were 0.08 (95% CI 0.06, 0.10) and 0.05 (95% CI 0.02, 0.08) scores. The chance of having complications in the LSF group was 1.69 (95% CI 1.07, 2.60), which was statistically significantly higher than in the HP group.

CONCLUSION

LSF have higher shoulder function scores (CMS) and lower postoperative pain when compared to HP fixation; however, there are higher complication rates with LSF when compared to hook plating.

LEVEL OF EVIDENCE

IV.

Prevalence of remaining horizontal instability in high-grade acromioclavicular joint injuries surgically managed

PURPOSE

To determine the prevalence of remaining horizontal instability in high-grade acromioclavicular joint (ACJ) injuries surgically managed by means of four different surgical strategies and to assess its relation to the clinical outcomes and the quality of life.

METHODS

In this multicentric non-randomized retrospective study, 53 patients with high-grade ACJ injuries surgically managed (by means of open or arthroscopic surgery) were clinically and radiographically assessed at 24 months or more after shoulder surgery. The presence of post-surgical remaining horizontal instability was evaluated by means of Alexander or axillary X-ray views. The study population was divided into two groups: patients with evidence of post-surgical remaining horizontal instability and patients without evidence of post-surgical remaining horizontal instability at the last follow-up visit. The relationship between remaining horizontal instability and the quality-of-life questionnaires was analyzed.

RESULTS

18.87% (10/53) of the Alexander or axillary X-rays views showed post-surgical remaining horizontal instability at the last follow-up visit (INSTAB-group). Results of the questionnaires were: (1) physical SF36 score (INSTAB-group 57.02 ± 3.17  and NO-INSTAB-group 57.66 ± 3.30, p = 0.583); (2) mental SF36 score (INSTAB-group 53.95 ± 3.98  and NO-INSTAB-group 55.71 ± 3.30, p = 0.150); (3) NRS for pain (INSTAB-group 1.30 ± 1.49 and NO-INSTAB-group 0.83  ± 1.08, p = 0.260); (4) DASH questionnaire (INSTAB-group 5.27 ± 5.42 and NO-INSTAB-group 3.06 ± 2.30, p = 0.049); (5) Constant score (INSTAB-group 93.4 ± 3.5 and NO-INSTAB-group 94.83  ± 4.3, p = 0.333); and Global satisfaction (INSTAB-group 8.7  ± 0.95 and NO-INSTAB-group 8.64 ± 1.03, p = 0.874).

CONCLUSION

Independently of the type of procedure, post-surgical remaining horizontal instability was present in almost one-fifth of the patients, and this group of patients showed a significantly worse DASH score. The addition of an acromioclavicular augmentation might have to be considered, taking into account that its absence may have a negative impact in terms of shoulder disabilities.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

[Injuries of the acromioclavicular joint: Hook plate versus arthroscopy]

Acute acromioclavicular (AC) joint injuries are common in clinical practice. The hook plate is a well-established conventional operative treatment option for high grade instability; however, arthroscopically-assisted flexible double button techniques are increasingly being used. Both procedures lead to good or excellent results. The advantages of the hook plate are the simple surgical technique and the possibility of an early functional aftercare. The minimally invasive one-step procedure with the possibility of identification and treatment of frequently concomitant glenohumeral pathologies is advantageous for the arthroscopic technique but mobilization is more restrictive. Available comparative studies have shown no significant clinical differences but a tendency towards better results with a higher degree of acceptance among patients for the arthroscopic and minimally invasive non-rigid double button procedures.

Unstable acromioclavicular joint injuries: Is there really a difference between surgical management in the acute or chronic setting?

AIM

To compare the outcomes of unstable ACJ injuries managed with an arthroscopy-assisted anatomic reconstruction of the coracoclavicular (CC) ligaments in the acute and chronic setting.

METHODS

A retrospective revision was performed. The SF36, visual analog scale for pain, DASH questionnaire, constant score and the global satisfaction were assessed at the last follow-up visit.

RESULTS

22 patients were included. Results of the questionnaires assessed at the last follow-up visit showed no significant differences between the study groups.

CONCLUSION

Management of ACJ injuries in the acute or chronic setting may involve comparable outcomes if biological and mechanical aspects are considered.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Acute high-grade acromioclavicular joint injuries: quality of life comparison between patients managed operatively with a hook plate versus patients managed non-operatively

INTRODUCTION

Surgical indication for acromioclavicular joint (ACJ) injuries still represents a reason for shoulder and trauma debate. In high-grade injuries, surgery is advocated because some of the non-operatively managed patients may have persistent shoulder pain that could make them unable to return to their previous activity. It has been shown that many of the patients with high-grade ACJ injuries that are managed non-operatively involve the development of scapular dyskinesis, situation that may result in loss of strength and weakness. On the other side, it has been widely reported that the period while the hook plate is present involves functional limitations and pain. The purpose of this study was to compare the quality of life (QoL) of patients with acute high-grade ACJ injuries (Rockwood grade III-V), managed operatively with a hook plate versus the QoL of patients managed non-operatively, 24 months or more after shoulder injury.

PATIENTS AND METHODS

Patients with acute high-grade ACJ injuries managed operatively (hook plate) or non-operatively, between 2008 and 2012 were included. The QoL was evaluated by means of the Health Survey questionnaire (SF36), the Visual Analogue Scale (VAS) for pain, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Constant score and the Global Satisfaction (scale from 0 to 10) assessed at the last follow-up visit. The presence of scapular dyskinesis was assessed. Comparison between groups was made.

RESULTS

Thirty-two patients were included: 11 hook plate-group (PLATE group) (5 Rockwood III and 6 V) and 21 conservative-group (CONS group) (4 Rockwood III and 17 V). The mean age was 41 [19-55] years old for the PLATE group and 38 [19-55] for the CONS group (p = 0.513). The mean follow-up was 32.50 ± 11.64 months for the PLATE group and 34.77 ± 21.98 months for the CONS group (p = 0.762). The mean results of the questionnaires assessed at the last follow-up visit were: (1) physical SF36 score (PLATE group 53.70 ± 4.33 and CONS group 52.10 ± 6.11, p = 0.449); (2) mental SF36 score (PLATE group 53.06 ± 6.10 and CONS group 56.99 ± 6.47, p = 0.110); (3) VAS for pain (PLATE group 1.45 ± 1.51 and CONS group 1.50 ± 1.79, p = 0.943); (4) DASH score (PLATE group 4.79 ± 5.60 and CONS group 5.83 ± 6.76, p = 0.668); (5) Constant score (PLATE group 91.36 ± 6.84 and CONS group 91.05 ± 7.35, p = 0.908); (6) Global Satisfaction (PLATE group 8.00 ± 1.18 and CONS group 8.45 ± 1.73, p = 0.449). There was evidence of scapular dyskinesis in 18 % (2/11) of the patients of the PLATE group and in 52.4 % (11/21) of the patients of the CONS group (p = 0.127).

CONCLUSIONS

Patients with acute high-grade ACJ injuries managed operatively with a hook plate may have the same QoL and self-reported questionnaires than patients with high-grade ACJ injuries managed non-operatively, 24 months or more after shoulder injury. If surgery is advocated for this type of injury, the orthopedic population must be aware that the hook-plate system might not represent the most suitable option.

LEVEL OF EVIDENCE

Level IV therapeutic; retrospective comparative study.

Injury patterns of the acromioclavicular ligament complex in acute acromioclavicular joint dislocations: a cross-sectional, fundamental study

BACKGROUND

Horizontal instability impairs clinical outcome following acute acromioclavicular joint (ACJ) reconstruction and may be caused by insufficient healing of the superior acromioclavicular ligament complex (ACLC). However, characteristics of acute ACLC injuries are poorly understood so far. Purposes of this study were to identify different ACLC tear types, assess type-specific prevalence and determine influencing cofactors.

METHODS

This prospective, cross-sectional study comprised 65 patients with acute-traumatic Rockwood-5 (n = 57) and Rockwood-4 (n = 8) injuries treated operatively by means of mini-open ACJ reduction and hook plate stabilization. Mean age at surgery was 38.2 years (range, 19-57 years). Standardized pre- and intraoperative evaluation included assessment of ACLC tear patterns and cofactors related to the articular disc, the deltoid-trapezoidal (DT) fascia and bony ACJ morphology. Articular disc size was quantified as 0 = absent, 1 = remnant, 2 = meniscoid and 3 = complete.

RESULTS

All patients showed complete ruptures of the superior ACLC, which could be assigned to four different tear patterns. Clavicular-sided (AC-1) tears were observed in 46/65 (70.8 %), oblique (AC-2) tears in 12/65 (18.5 %), midportion (AC-3) tears in 3/65 (4.6 %) and acromial-sided (AC-4) tears in 4/65 (6.1 %) of cases. Articular disc size manifestation was significantly (P < .001) more pronounced in patients with AC-1 tears (1.89 ± 0.57) compared to patients with AC-2 tears (0.67 ± 0.89). Other cofactors did not influence ACLC tear patterns. ACLC dislocation with incarceration caused mechanical impediment to anatomical ACJ reduction in 14/65 (21.5 %) of cases including all Rockwood-4 dislocations. Avulsion "in continuity" was a consistent mode of failure of the DT fascia. Type-specific operative strategies enabled anatomical ACLC repair of all observed tear types.

CONCLUSIONS

Acute ACLC injuries follow distinct tear patterns. There exist clavicular-sided (AC-1), oblique (AC-2), midportion (AC-3) and acromial-sided (AC-4) tears. Articular disc size was a determinant factor of ACLC tear morphology. Mini-open surgery was required in Rockwood-4 and a relevant proportion of Rockwood-5 dislocations to achieve both anatomical ACLC and ACJ reduction. Type-specific operative repair of acute ACLC tears might promote biological healing and lower rates of horizontal ACJ instability following acute ACJ reconstruction.

Radiographic failure and rates of re-operation after acromioclavicular joint reconstruction: a comparison of surgical techniques

AIMS

To compare radiographic failure and re-operation rates of anatomical coracoclavicular (CC) ligament reconstructional techniques with non-anatomical techniques after chronic high grade acromioclavicular (AC) joint injuries.

PATIENTS AND METHODS

We reviewed chronic AC joint reconstructions within a region-wide healthcare system to identify surgical technique, complications, radiographic failure and re-operations. Procedures fell into four categories: (1) modified Weaver-Dunn, (2) allograft fixed through coracoid and clavicular tunnels, (3) allograft loop coracoclavicular fixation, and (4) combined allograft loop and synthetic cortical button fixation. Among 167 patients (mean age 38.1 years, (standard deviation (sd) 14.7) treated at least a four week interval after injury, 154 had post-operative radiographs available for analysis.

RESULTS

Radiographic failure occurred in 33/154 cases (21.4%), with the lowest rate in Technique 4 (2/42 4.8%, p = 0.001). Half the failures occurred by six weeks, and the Kaplan-Meier survivorship at 24 months was 94.4% (95% confidence interval (CI) 79.6 to 98.6) for Technique 4 and 69.9% (95% CI 59.4 to 78.3) for the other techniques when combined. In multivariable survival analysis, Technique 4 had better survival than other techniques (Hazard Ratio 0.162, 95% CI 0.039 to 0.068, p = 0.013). Among 155 patients with a minimum of six months post-operative insurance coverage, re-operation occurred in 9.7% (15 patients). However, in multivariable logistic regression, Technique 4 did not reach a statistically significant lower risk for re-operation (odds ratio 0.254, 95% CI 0.05 to 1.3, p = 0.11).

CONCLUSION

In this retrospective series, anatomical CC ligament reconstruction using combined synthetic cortical button and allograft loop fixation had the lowest rate of radiographic failure.

TAKE HOME MESSAGE

Anatomical coracoclavicular ligament reconstruction using combined synthetic cortical button and allograft loop fixation had the lowest rate of radiographic failure.

Management of acute unstable acromioclavicular joint injuries

Surgical management of acute unstable acromioclavicular joint injuries should be focused on realigning the torn ends of the ligaments to allow for healing potential. The most widely utilized treatment methods incorporate the use of metal hardware, which can alter the biomechanics of the acromioclavicular joint. This leads to a second surgical procedure for hardware removal once the ligaments have healed. Patients with unstable acromioclavicular joint injuries managed with arthroscopy-assisted procedures have shown good and excellent clinical outcomes, without the need for a second operation. These procedures incorporate a coracoclavicular suspension device aimed to function as an internal brace, narrowing the coracoclavicular space thus allowing for healing of the torn coracoclavicular ligaments. The lesser morbidity of a minimally invasive approach and the possibility to diagnose and treat concomitant intraarticular injuries; no obligatory implant removal, and the possibility of having a straight visualization of the inferior aspect of the base of the coracoid (convenient when placing coracoclavicular fixation systems) are the main advantages of the arthroscopic approach over classic open procedures. This article consists on a narrative review of the literature in regard to the management of acute acromioclavicular joint instability.

Comparison of Short-term Complications Between 2 Methods of Coracoclavicular Ligament Reconstruction: A Multicenter Study

Background:

Numerous techniques have been used to treat acromioclavicular (AC) joint dislocation, with anatomic reconstruction of the coracoclavicular (CC) ligaments becoming a popular method of fixation. Anatomic CC ligament reconstruction is commonly performed with cortical fixation buttons (CFBs) or tendon grafts (TGs).

Purpose:

To report and compare short-term complications associated with AC joint stabilization procedures using CFBs or TGs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We conducted a retrospective review of the operative treatment of AC joint injuries between April 2007 and January 2013 at 2 institutions. Thirty-eight patients who had undergone a procedure for AC joint instability were evaluated. In these 38 patients with a mean age of 36.2 years, 18 shoulders underwent fixation using the CFB technique and 20 shoulders underwent reconstruction using the TG technique.

Results:

The overall complication rate was 42.1% (16/38). There were 11 complications in the 18 patients in the CFB group (61.1%), including 7 construct failures resulting in a loss of reduction. The most common mode of failure was suture breakage (n = 3), followed by button migration (n = 2) and coracoid fracture (n = 2). There were 5 complications in the TG group (25%), including 3 cases of asymptomatic subluxation, 1 symptomatic suture granuloma, and 1 superficial infection. There were no instances of construct failure seen in TG fixations. CFB fixation was found to have a statistically significant increase in complications (P = .0243) and construct failure (P = .002) compared with TG fixation.

Conclusion:

CFB fixation was associated with a higher rate of failure and higher rate of early complications when compared with TG fixation.

Comparison of surgical outcomes between fixation with hook plate and loop suspensory fixation for acute unstable acromioclavicular joint dislocation: a systematic review and meta-analysis

Treatment of acute (≤4 weeks) high-grade acromioclavicular (AC) joint separation (types III-VI) is still controversial. Currently, the two modern techniques that are widely used include hook plate fixation and coracoclavicular (CC) ligament fixation using a suspensory loop device (tightrope, synthetic ligament or absorbable polydioxansulfate sling). These techniques are both reported to have superior clinical outcomes. This systematic review and meta-analysis aimed to assess and compare clinical outcomes of hook plate fixation versus fixation of the CC ligament using a loop suspensory fixation (LSF) device for the treatment of AC joint injury. These clinical outcomes consist of the Constant-Murley score (CMS), pain visual analog score (VAS) and postoperative complications. Relevant comparative studies were identified from MEDLINE and Scopus from inception to October 5, 2015. Five of 571 studies were eligible; 5, 3, 3, and 5 studies were included in the pooling of CMS, pain VAS, surgical time and postoperative complications, respectively. The unstandardized mean difference (UMD) of the CMS for LSF was 4.43 [95 % confidence interval (CI) 0.73, 8.14], which was statistically significantly higher than the CMS in hook plate fixation. For VAS, the UMD was 0.02 points (95 % CI -3.54, 3.73) higher than LSF but without statistical significance. The surgical time of LSF was 16.21 min (95 % CI 6.27, 26.15) statistically significantly higher than hook plate fixation. LSF had a lower chance of postoperative complications by 0.62 units (95 % CI 0.30, 1.32) when compared to hook plate fixation, but this also was not statistically significant. In acute high-grade AC joint injuries, loop suspensory fixation had higher postoperative functional CMS and mean surgical time when compared to hook plate fixation. However, for postoperative VAS and complication rates, there were no statistically significant differences between groups.

Comparing mini-open and arthroscopic acromioclavicular joint repair: functional results and return to sport

INTRODUCTION

Acromioclavicular joint (ACJ) dislocation is a common injury that can result from sports activities. The surgical technique for the treatment of Type III and Type IV injuries, according to the Rockwood classification, remains controversial. The purpose of the study was to determine the functional outcome after minimally invasive and arthroscopic surgery. The mini-open surgery was done with MINAR^® system, whereas the arthroscopic technique was done with Dog Bone^TM Button.

STUDY DESIGN

Retrospective Cohort study.

METHODS

We reviewed 31 who were surgically treated for acute acromioclavicular dislocation Type III and Type IV (2012-2015). We excluded subjects with chronic dislocation or other injury. We selected 16 patients (average age 37).  Half of the sample patients were treated with mini-open surgery with the MINAR^® system, and the other half of the patients were treated with the Dog Bone arthroscopic technique. The Constant Shoulder Score, the Oxford Shoulder Score, the Simple Shoulder Test and the Subjective Patient Outcome for Return to Sports (SPORTS) score were used to assess functional outcome of the treated shoulder.

RESULTS

Mean follow-up was 13 months (range 6-27 months). The mean Constant Shoulder Score was 91.10 (range 82.76-96.66), Oxford Shoulder Score was 46.19 (range 42.00-48.00), the Simple Shoulder Test was 10.50 (range 9.00-12.00), and the SPORTS score was 7.88 (range 3-10). There is a statistically significant difference between the sample operated with the mini-open surgery and the group operated with arthroscopic technique. The probability of return to their sport, according to the results of the SPORTS score, was significantly higher for patients treated with the MINAR^® system (p < 0.001). However, the objective parameter of Constant scale is statistically better in patients operated by arthroscopic technique (p < 0.05; p < 0.001).

CONCLUSION

Restoration of ACJ anatomy is the key to a successful therapy. The surgical technique should be personalized. The miny-open surgery and also the arthroscopic surgery are adequate with good clinical results. However, according to the SPORTS score, the patients treated with mini-open surgery returned to their sport with less pain and better performance than those belonging to the other group.

Surgical treatment of acute acromioclavicular joint dislocations: hook plate versus minimally invasive reconstruction

PURPOSE

This study was performed to compare the clinical results of a minimally invasive technique for acute acromioclavicular (AC) joint dislocation repair with the traditional hook plate fixation.

METHODS

Forty-four patients with an acute (within 2 weeks after trauma) complete AC joint separation (35 male, nine female; median age 36.2 years, range 18-56) underwent surgical repair with either a minimally invasive AC joint repair or a conventional hook plate. Functional outcome was evaluated using the Constant-Murley Score (CMS), the TAFT score and the AC joint instability score (ACJI). Radiographic evaluation was performed with bilateral anterior-posterior (a.p.) stress and Alexander views.

RESULTS

All patients were available after a median follow-up of 32 months (range 24-51). There were no significant differences in the mean CMS, Taft score and the ACJI between the two groups. The radiological assessment revealed no significant difference in the coracoclavicular distance. In both groups, a slight loss of reduction was observed. Periarticular ossification was seen in 11 patients of the minimally invasive AC joint repair and eight patients of the hook plate group but this did not affect the final outcome. Hook plates were removed after a median interval of 11.9 weeks (range 10-13).

CONCLUSION

Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation. However, in the hook plate group a second operation is mandatory for plate removal.

LEVEL OF EVIDENCE

III.

Return-to-activity after anatomical reconstruction of acute high-grade acromioclavicular separation

Background

To evaluate return-to-activity (RtA) after anatomical reconstruction of acute high-grade acromioclavicular joint (ACJ) separation.

Methods

A total of 42 patients with anatomical reconstruction of acute high-grade ACJ-separation (Rockwood Type V) were surveyed to determine RtA at a mean 31 months follow-up (f-u). Sports disciplines, intensity, level of competition, participation in overhead and/or contact sports, as well as activity scales (DASH-Sport-Module, Tegner Activity Scale) were evaluated. Functional outcome evaluation included Constant score and QuickDASH.

Results

All patients (42/42) participated in sporting activities at f-u. Neither participation in overhead/contact sports, nor level of activity declined significantly (n.s.). 62 % (n = 26) of patients reported subjective sports specific ACJ integrity to be at least the same as prior to the trauma. Sporting intensity (hours/week: 7.3 h to 5.4 h, p = .004) and level of competition (p = .02) were reduced. If activity changed, in 50 % other reasons but clinical symptoms/impairment were named for modified behavior. QuickDASH (mean 6, range 0–54, SD 11) and DASH-Sport-Module (mean 6, range 0–56, SD 13) revealed only minor disabilities at f-u. Over time Constant score improved significant to an excellent score (mean 94, range 86–100, SD 4; p < .001). Functional outcome was not correlated with RtA (n.s.).

Conclusion

All patients participated in sporting activities after anatomical reconstruction of high-grade (Rockwood Type V) ACJ-separation. With a high functional outcome there was no significant change in activity level (Tegner) and participation in overhead and/or contact sports observed. There was no correlation between functional outcome and RtA. Limiting, there were alterations in time spent for sporting activities and level of competition observed. But in 50 % those were not related to ACJ symptoms/impairment. Unrelated to successful re-established integrity and function of the ACJ it should be considered that patients decided not return-to-activity but are very content with the procedure.

Acute high-grade acromioclavicular joint injuries treatment: Arthroscopic non-rigid coracoclavicular fixation provides better quality of life outcomes than hook plate ORIF

INTRODUCTION

Treatment of acute high-grade acromioclavicular joint (ACJ) injuries with metal hardware alters the biomechanics of the ACJ, implying a second surgery for hardware removal. The period during which the plate is present involves functional limitations, pain and a risk factor for the development of hardware-related-injuries. Arthroscopy-assisted procedures compared to open-metal hardware techniques offer: less morbidity, the possibility to treat associated lesions and no need for a second operation. The aim was to compare the Quality of life (QoL) of patients with acute high-grade ACJ injuries (Rockwood grade III-V), managed arthroscopically with a non-rigid coracoclavicular (CC) fixation versus the QoL of patients managed with a hook plate, 24 months or more after their shoulder injury.

PATIENTS AND METHODS

A retrospective revision of high-grade ACJ injuries managed in three institutions was performed. Patients treated by means of an arthroscopy-assisted CC fixation or by means of a hook plate were included. The inclusion period was between 2008 and 2012. The QoL was evaluated at the last follow-up visit by means of the SF36, the visual analog scale (VAS), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Constant score and the global satisfaction (scale from 0 to 10). The presence of scapular dyskinesis and remaining vertical instability were evaluated. Comparison between groups was performed.

RESULTS

Thirty-one patients were included: 20 arthroscopy-group (ARTH group: 3 Rockwood III, 3 IV and 14 V) and 11 hook plate-group (HOOK group: 5 Rockwood III and 6 V). The mean age was 36 [25-52] year-old for the ARTH group and 41 [19-55] for the HOOK group (P=0.185). The mean results of the questionnaires were: (1) physical SF36 score (ARTH group 58.24±2.16 and HOOK group 53.70±4.33, P<0.001); (2) mental SF36 score (ARTH group 56.15±2.21 and HOOK group 53.06±6.10, P=0.049); (3) VAS (ARTH group 0.40±0.50 and HOOK group 1.45±1.51, P=0.007); (4) DASH (ARTH group 2.98±2.03 and HOOK group 4.79±5.60, P=0.200); (5) Constant score (ARTH group 95.30±2.45 and HOOK group 91.36±6.84, P=0.026); (6) global satisfaction (ARTH group 8.85±0.93 and HOOK group 8.00±1.18, P=0.035). There was evidence of scapular dyskinesis in 15% (3/20) of the patients of the ARTH group and in 18% (2/11) of the patients of the HOOK group (P=1.000). Remaining vertical ACJ instability was observed in 40% (8/20) of the patients of the ARTH group and in 36.36% (4/11) of the patients of the HOOK group (P=1.000).

CONCLUSION

Patients with acute high-grade ACJ injuries managed arthroscopically with a non-rigid CC fixation seem to have a better QoL than patients managed with a hook plate.

LEVEL OF EVIDENCE

Level IV therapeutic; retrospective comparative study.

Arthroscopic fixation for acute acromioclavicular joint disruption using the TightRope device

PURPOSE

To review outcome after arthroscopic fixation for acute acromioclavicular (AC) joint dislocation using the TightRope device.

METHODS

Records of 15 men and 2 women aged 19 to 52 (mean, 35) years who underwent arthroscopic fixation using the TightRope device for acute (<3 weeks) AC joint dislocation of Rockwood type III (n=6), type IV (n=1), and type V (n=10) were reviewed. Outcome was evaluated using the Constant score. The coracoclavicular (CC) distance before and after surgery was compared.

RESULTS

The mean follow-up period was 22.1 (range, 12-37) months. The mean time to return to work was 4 (range, 1.5-12) months, excluding one failure. The mean postoperative Constant score was 86.4 (range, 63-96). The CC distance decreased from 21.5±5.2 mm preoperatively to 9.8±3.5 mm at 6 months and to 10±3.2 mm at one year. There was no over-correction. All patients had satisfactory outcome except for one who had rupture of the TightRope suture at 6 months. Two patients had partial loss of reduction (≥2 mm) after 3 to 6 months secondary to osteolysis at the clavicular button site.

CONCLUSION

Arthroscopic fixation using the TightRope device for acute AC joint dislocation achieves satisfactory outcome.

Arthroscopic treatment of acute acromioclavicular dislocations using a double button device: Clinical and MRI results

INTRODUCTION

Arthroscopic treatment of acute grade 3 and 4 acromioclavicular dislocation is controversial, due to the risk of recurrence and of postoperative reduction defect. The purpose of the present study was to investigate whether the healing of the acromioclavicular (AC) and coracoclavicular (CC) ligaments and the accurate 3D positioning parameters of the AC joint using MRI were correlated with satisfactory functional outcome.

MATERIAL

Thirty-nine patients were enrolled from 2009 to 2011 and managed arthroscopically by CC lacing using a double-button device.

METHODS

Clinical assessment included the Shoulder and Hand (QuickDash) score, Constant-Murley score and visual analog scale (VAS) for residual pain. Time and rate to return to work and return to sport were assessed according to type of sport and work. Postoperative complications were recorded. Radiological examination consisted of anteroposterior clavicle and lateral axillary radiographs. AC ligament healing and 3D joint congruency were assessed on MRI and correlated to the clinical results.

RESULTS

Mean patient age was 35.7 years (range, 20-55). Mean follow-up was 42.3±10.6 months (range, 24-60). At final follow-up, mean QuickDash score, Constant score and VAS were respectively 1.7±4 (range, 0-11), 94.7±7.3 (range, 82-100) and 0.5±1.4 (range, 0-2). Thirty-five (90%) patients were able to resume work, including heavy manual labor, and sport. Radiology found accurate 3D joint congruency in 34 patients (87%) and CC and AC ligament healing in 36 (93%). Complications included reduction loss at 6 weeks in 3 patients, requiring surgical stabilization. Satisfactory functional results were associated with accurate AC joint congruency in the coronal and axial planes (P<0.05) and good AC and CC ligament healing (P<0.04). An initial 25% reduction defect in the coronal plane was not associated with poor functional results (P=0.07).

CONCLUSION

Arthroscopic treatment by CC lacing satisfactorily restored ligament and joint anatomy in the present series. These satisfactory anatomic results correlated with good clinical outcome encourage continuing with this technique.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic-Assisted Acromioclavicular Joint Reconstruction Using the TightRope Device With Allograft Augmentation: Surgical Technique

Surgical management of acromioclavicular (AC) joint separations remains challenging, especially in the revision setting. Most commonly, Rockwood type I and II injuries are managed nonoperatively whereas type IV, V, and VI injuries are managed with surgery. Type III separations are more controversial, with evidence supporting both nonoperative and operative treatment options. Multiple different arthroscopic techniques have been described; however, there is no current gold standard. AC joint reconstruction with the TightRope device (Arthrex, Naples, FL) with the patient in the lateral decubitus position is a method of restoring joint stability that allows for a minimally invasive, low-profile fixation construct using a single drill hole through the clavicle. Allograft augmentation of this fixation construct helps to eliminate the stress risers potentially created by this device while increasing overall repair construct stability. The purpose of this article is to describe the surgical technique for arthroscopic AC joint reconstruction using a TightRope device with allograft augmentation.

In vivo analysis of acromioclavicular joint motion after hook plate fixation using three-dimensional computed tomography

BACKGROUND

The clavicle hook plate can be used to treat acromioclavicular and coracoclavicular ligament injury or distal clavicular fracture with comminution. However, the hook plate can induce subacromial impingement, resulting in discomfort from the hardware.

METHODS

Our inclusion criteria were (1) men and women aged older than 20 years and (2) the presence of comminuted distal clavicular fractures (Neer type IIB) fixed with a hook plate (Synthes, Oberdorf, Switzerland). Three-dimensional computed tomography was obtained before removal of the hook plate. Seven patients were enrolled prospectively. The mean age was 42 years (range, 24-60 years). Zero degree images and abduction images were obtained. The sagittal cut surface was obtained 5 mm medial from the distal clavicle. The equator of the cut surface of the clavicle was compared with the full abduction model to analyze rotation. The center of the cut surface of the clavicle was compared with the full abduction model to analyze translation.

RESULTS

The average difference in rotation of the distal clavicle between both shoulders was 16° (range, 3°-22°; P = .001). The mean difference in anterior translation of the distal clavicle was 2.2 mm (range, -0.7 to 5.6 mm; P = .030).

CONCLUSION

Hook plate fixation at the acromioclavicular joint causes decreased internal rotation and increased anterior translation of the distal clavicle with respect to the medial acromion, indicating that the scapula relative to the thorax has decreased posterior tilting and increased external rotation in shoulders fixed using a hook plate.

[Therapy of acute acromioclavicular joint instability. Meta-analysis of arthroscopic/minimally invasive versus open procedures]

BACKGROUND

A variety of surgical procedure are desrcibed for the treatment of acute acromioclavicular (AC-) joint injuries. Beside open techniques arthroscopic assisted procedures spread widely. Each surgical technique offers advantages and disadvantages, but none is currently accepted as a gold standard. Therefore, the study aims to review the evidence for arthroscopic and open surgical procedures in the treatment of acute AC joint instabilities.

MATERIAL AND METHODS

According to the Cochrane Handbook for Systematic Reviews of Interventions we conducted a defined search of Medline and Embase database for articles publisher over the last ten years.

RESULTS

The search resulted in 961 studies of which 32 were included in this review and 3 studies were suitable for a meta-analysis. The functional outcome (Constant score) showed a tendency towards better results after arthroscopic procedures (weighted mean difference 5.60, 95% confidence interval 0.36-10.64). There were no significant differences with respect to complication rates, secondary dislocation in the vertical plane, revision surgery and AC joint instability.

CONCLUSION

There is insufficient evidence to inform the surgical management of acute AC joint instability. Due to inconsistent study designs there is no evidence for a general superiority of any of the open or arthroscopic procedures. Randomized, controlled studies are necessary to demonstrate whether arthroscopic techniques show a potential benefit in terms of a better functional outcome.

Why does minimally invasive coracoclavicular ligament reconstruction using a flip button repair technique fail? An analysis of risk factors and complications

PURPOSE

Aim of the present study was to evaluate the risk factors for the failure of coracoclavicular ligament reconstruction using a flip button repair technique and to analyse complications related to this procedure.

METHODS

Seventy-one patients (3 female, 68 male) underwent surgical treatment using a flip button repair technique for an acute acromioclavicular joint dislocation. The following factors and its impact on clinical and radiographic outcome were assessed: age at trauma, interval between trauma and surgery, degree of displacement (according to Rockwood's classification), coracoid button position, button migration and post-operative appearance of ossifications.

RESULTS

Sixty-three patients were available for follow-up. The overall Constant score was 95.2 points (range 61-100 points) compared to 97 points (range 73-100 points) for the contralateral side (p = 0.05). Nine patients (14.3 %) needed surgical revision. Inappropriate positioning of the coracoid bone tunnel with subsequent button dislocation was the most frequently observed mode of failure (6 cases, 9.5 %). Button migration into the clavicle was associated with loss of reduction (p = 0.02). The patient's age at the time of trauma had a significant impact on the clinical outcome, whereas younger patients achieved better results (p = 0.02). The interval between trauma and surgery did not significantly affect the outcome (n.s.).

CONCLUSION

Good to excellent clinical results can be achieved with the presented surgical technique. The age of the patient at trauma had a significant influence on the functional outcome. Furthermore, placement of the coracoid button centrally under the coracoid base is crucial to prevent failure.

LEVEL OF EVIDENCE

IV.

Current state of treatment of acute acromioclavicular joint injuries in Germany: is there a difference between specialists and non-specialists? A survey of German trauma and orthopaedic departments

PURPOSE

The purpose of this study was to evaluate currently preferred treatment strategies as well as the acceptance of new arthroscopic techniques among German orthopaedic surgeons. We assumed that surgeons specialized in shoulder surgery and arthroscopy would treat acute acromioclavicular joint dislocations different to non-specialized surgeons.

METHODS

Seven hundred and ninety-six orthopaedic and/or trauma departments were found through the German hospital directory of 2012. Corresponding websites were searched for the email address of the chair of shoulder surgery (if applicable) or the department. Seven hundred forty-six emails with the request for study participation including a link to an online survey of 36 questions were sent. In 60 emails, the recipient was unknown.

RESULTS

Two hundred and three (30 %) surgeons participated in the survey. one hundred and one were members of the AGA (German-speaking Society for Arthroscopy and Joint-Surgery) and/or of the DVSE (German Association of Shoulder and Elbow Surgery) and regarded as specialists, while 102 were non-members and regarded as non-specialists. According to the treatment of Rockwood I/II and IV-VI injuries, no significant differences were found. Seventy-four % of non-specialists and 67 % of specialists preferred surgical treatment for Rockwood III injuries (P = 0.046). Non-specialists would use the hook plate in 56 % followed by the TightRope in 16 %; specialists would use the TightRope in 38 % followed by the hook plate in 32 % (P = 0.004).

CONCLUSIONS

The majority of German orthopaedic and trauma surgeons advise surgical treatment for Rockwood III injuries. Specialists recommend surgery less often. Non-specialists prefer the hook plate, whereas specialists prefer the arthroscopic TightRope technique.

LEVEL OF EVIDENCE

Observational survey, Level IV.