Current concepts in the treatment of acromioclavicular joint dislocations

Arthroscopy-Assisted All-Suture Coracoclavicular and Acromioclavicular Joint Stabilization in Acute Acromioclavicular Joint Injuries

The existing literature agrees on surgical management for Rockwood grade IV and V injuries, but there is no consensus which type of surgery is the most appropriate one. More than 150 surgeries have been described for this condition in the literature. In an injury of less than 3 weeks, most surgeons prefer suture-button devices for coracoclavicular stabilization. Recent biomechanical studies have demonstrated that coracoclavicular stabilization provides good vertical stability but poor horizontal stability of acromioclavicular joint. Hence, they recommend acromioclavicular stabilization along with coracoclavicular stabilization. The use of a suture-button device for coracoclavicular stabilization requires special implants and instruments along with high surgical skills to drill precisely placed holes in the clavicle and the coracoid in order to avoid fractures from the drill hole. Due to relatively smaller clavicle and coracoid in Asian population, making holes in the clavicle and the coracoid has increased risk of fracture. We describe a technique in which no drill holes are made in the clavicle or the coracoid. In our technique, suture tape is used, which is looped around the coracoid and the clavicle, and the limbs are tied over the clavicle to maintain the coracoclavicular distance. The remaining limbs of suture tape is further looped through the tunnels made in acromion and tied over the acromion to augment the acromioclavicular ligament. The potential advantages of this technique are no costly implant and instruments are required, avoidance of complications associated with drill holes in coracoid and clavicle, both coracoclavicular and acromioclavicular joints are stabilized, direct repair of the acromioclavicular ligament can be performed, and no need of second surgery for implant removal.

Biomechanical analysis of a novel clavicular hook plate for the treatment of acromioclavicular joint dislocation: A finite element analysis

BACKGROUND

Clavicular hook plates are frequently used in clinical orthopedics to treat acromioclavicular joint dislocation. However, patients often exhibit acromial osteolysis and peri-implant fracture after hook plate fixation. To solve the above problems, we developed a novel double-hook clavicular plate and used finite element analysis (FEA) to investigate its biomechanical properties.

METHODS

A finite element (FE) model was constructed and validated. Then, a double-hook clavicular plate, a single-hook clavicular plate, and an anatomical double-hook clavicular plate was implanted into the acromioclavicular joint and fixed with screws in groups 1, 2 and 3, respectively. Finally, a load was applied, and some indicators were recorded and analyzed.

RESULTS

For both the proximal clavicular rotation angle and the distal clavicular displacement, the range of motion in groups 1 and 3 was more than 90% lower than that in group 2. The maximum von Mises stress of the clavicle in groups 1 and 3 was more than 45% lower than that in group 2. The maximum stress of the acromion in group 2 was significantly higher than that in groups 1 and 3, and that in group 3 was less than that in group 1, for both cortical and cancellous bone.

CONCLUSIONS

The double-hook clavicular plate could immediately reconstruct the stability of the acromioclavicular joint, effectively reducing the stress of the bone around the clavicle and screws. Additionally, the double-hook clavicular plate could reduce the peak stress of the acromion and produce a more uniform stress distribution.

Acromioclavicular joint separation treated with clavicular hook plate: a study of radiological and functional outcomes

INTRODUCTION

ACJ separation is a common shoulder injury. A variety of surgical techniques for high-grade ACJ separations have been described. A commonly used technique represents open reduction and fixation by a hook plate. Goal of the present study was to evaluate radiographic and functional outcome in patients with high-grade ACJ separations following surgical treatment with a hook plate before and after surgery as well as after hook plate removal.

MATERIALS AND METHODS

Patients undergoing surgery with a hook plate due to traumatic ACJ separation between 2012 and 2014 were included and examined during a follow-up control. Demographic and clinical data as well as radiographs pre- and postoperatively were evaluated. Additionally, range of motion, DASH Score and Constant-Murley Score (CMS) were analysed in a follow-up examination. Wilcoxon signed-rank test and Spearman's rank correlation were used for statistical analysis.

RESULTS

99 patients (88 m/11 w, 44 y) were included in the present study. 69 (64 m/5 w, 49 y) could be examined during long-term follow-up (38 month). After hook plate removal, the CCD increased significantly (13.7 ± 0.9 mm) compared to the hook plate in situ (9.9 ± 0.8 mm, p = 0.000001). 68% of all patients achieved a full range of motion post-operatively. Main limitations of range of motion affected external rotation as well as ante-/retroversion. Mean DASH Score was 5.6 ± 1 points and CMS 90.0 ± 1.4 points.

CONCLUSION

In contrast to a significant higher CCD after hook plate removal, nearly all patients achieved good to excellent functional results for DASH and CMS. This indicates that loss of reduction does not necessarily lead to poor functional outcome after ACJ separation surgery.

Long-term Outcome After Nonoperative Treatment for Rockwood I and II Acromioclavicular Joint Injuries

BACKGROUND

Rockwood I and II acromioclavicular joint injuries are generally treated nonoperatively. The long-term outcome is considered to be good but has not yet been properly investigated.

PURPOSE

To assess the long-term outcome after nonoperative therapy for Rockwood I and II acromioclavicular joint injuries regarding functional and radiologic outcome.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Eligible patients visited the emergency department between January 2003 and December 2015 and were ≥16 years old at the time of presentation. The main study parameters were the Constant score, the Disabilities of the Arm, Shoulder and Hand score, and the Simple Shoulder Test. The Constant score was measured in the injured and contralateral shoulders. Radiologic outcomes in both shoulders included joint displacement, joint space, degenerative changes, osteolysis of the distal clavicle, and ossification of the ligaments.

RESULTS

A total of 75 patients were included for follow-up. After a median follow-up of 85 months (interquartile range [IQR], 68.0-100.0), the mean Constant score in the injured shoulder for the total sample was 88.6 (SD, 12.7) as compared with 93.3 (SD, 8.7) in the contralateral shoulder, with a significant difference of 4.7 points between shoulders. The median Disabilities of the Arm, Shoulder and Hand score was 4.2 (IQR, 0.0-10.8), and the median Simple Shoulder Test was 100 (IQR, 91.7-100.0). The median patient satisfaction for the injured shoulder was 83 (IQR, 70.0-95.0). Regarding radiologic outcomes, for the injured shoulder versus the contralateral shoulder, patients had similar rates of degeneration (44% vs 46%) but more frequent osteolysis of the distal clavicle (31% vs 0%), ossification of the ligaments (29% vs 7%), and deformity of the distal clavicle (19% vs 0%).

CONCLUSION

Despite the frequent occurrence of radiographic changes, long-term functional outcome after Rockwood I and II acromioclavicular joint injuries is good, with only clinically nonrelevant functional differences between the injured and contralateral shoulders.

Nonanatomic and Suture-Based Coracoclavicular Joint Stabilization Techniques Provide Adequate Stability at a Lower Cost of Implants in Biomechanical Studies When Compared With Anatomic Techniques: A Systematic Review and Meta-Analysis

Purpose

To compare the stability and cost of the used implants in nonanatomic and anatomic acromioclavicular joint repair/reconstruction (ACCR) techniques tested in cadaveric shoulder biomechanical studies during the last decade.

Methods

A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and prospectively registered in PROSPERO. Two independent reviewers searched PubMed, Embase, and Virtual Health Library databases. Studies evaluating 3-direction stability under 70-N loads and load-to-failure protocols with servohydraulic testing systems were included. A meta-analysis of the mean differences of anterior, posterior, and superior direction; relative stability value in 3 directions; superior direction load-to-failure; stability/cost index; and load-to-failure/cost index was performed using a continuous random-effects model and 95% confidence interval.

Results

Eighteen articles were included. Both non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and load-to-failure. ACCR techniques were biomechanically better in terms of anterior stability (P = .04) and relative stability value (mean difference 64.08%, P = .015). However, supraphysiological stability and failure loads were achieved with non-ACCR techniques at a lower cost of implants. Techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes had the greatest stability/cost index and load-to-failure/cost index among the included techniques (confidence interval 99%).

Conclusions

Non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and failure loads in controlled biomechanical testing. However, non-ACCR and techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes provide supraphysiologic stability and failure loads at a lower cost of implants.

Clinical Relevance

Non-ACCR and suture-based techniques may provide more cost-effective and greater value treatment for acromioclavicular joint injury and could be considered in the surgical management of normal activity individuals and cost-sensitive populations.

Treatment of a Failed Type V Acromioclavicular Separation Due to Coracoid Fracture: Revision of Acromioclavicular-Coracoclavicular Reconstruction and Coracoid Fixation

Acromioclavicular (AC) injuries are common, especially in the young and active population. AC joint dislocations account for 8% of all joint dislocations and are even more common in contact sports. These injuries are graded as type I through type VI on the basis of the Rockwood classification method. Types I and II are generally treated without surgery whereas types IV, V, and VI are best treated operatively. Type III dislocations remain controversial in terms of treatment, and many surgeons recommend nonoperative treatment first and operative treatment in case of continued symptoms such as pain, instability, or shoulder girdle dysfunction. The goal of operative treatment is to restore AC joint stability, which involves addressing both the coracoclavicular and coracoacromial ligaments to achieve a desirable patient outcome. The objective of this Technical Note is to describe our technique for management of a failed acromioclavicular stabilization, treated with a coracoclavicular and AC joint capsular reconstruction using tibialis anterior and semitendinosus allografts.

Is coracoclavicular reconstruction necessary in hook plate fixation for acute unstable acromioclavicular dislocation?

Background

Acromioclavicular joint (ACJ) dislocation is a relatively common shoulder injury. For the treatment of cases of severe ACJ dislocation (Rockwood type III–V), hook plate fixation is an easy-to-master and minimally-invasive approach to surgical intervention. Over stress on the acromion following hook plate fixation often leads to acromial complications such as osteolysis and loss of reduction. We hypothesized that suspensory reconstruction alongside hook plate fixation might provide a superior stability and reduce complications as compared with hook plate fixation alone. The purpose of the study was to assess the clinical and radiographic outcomes of these two surgical modalities.

Methods

We retrospectively enrolled 49 patients with acute ACJ dislocation from May 2010 to December 2018. Among them, 19 patients received hook plate fixation only (HP group), and 19 underwent concomitant hook plate fixation and loop suspension fixation with two mersilene sutures (HM group). The demographic data of the patients were recorded and analyzed. All patients underwent a shoulder X-ray initially, immediately postoperatively, and at 1, 3, 6 and 12 months to measure the relative coracoclavicular distance (rCCD). Clinical assessment of shoulder function outcome was conducted using the Constant Murley Score (CMS); the University of California at Los Angeles (UCLA) Shoulder Score was also measured at the latest follow-up.

Results

There were no significant differences in the demographic data between the two groups. With regards to the CMS and the UCLA score, the HM group and HP group both had excellent outcomes, and no significant differences in scores were observed between groups (CMS: 93.90 ± 6.16 versus 94.47 ± 7.26, p = 0.47; UCLA score: 32.84 ± 2.91 versus 34.32 ± 1.16, p = 0.07). However, the HM group demonstrated substantial superiority in terms of maintenance of the rCCD over the HP group (91.47 ± 27.47 versus 100.75 ± 48.70, p = 0.015). In addition, there was less subacromial osteolysis in the HM group than the HP group (52.6% versus 15.8%, p = 0.038).

Conclusion

Both fixations yielded excellent functional outcomes. However, concomitant hook plate fixation with loop suspensory reconstruction demonstrated the fewer acromion complications and statistical differences in reduction maintenance with less clinical significance.

Dislocations of the acromioclavicular and sternoclavicular joint in children and adolescents: A retrospective clinical study and big data analysis of routine data

Background

Dislocations of the sternoclavicular joint (anterior/posterior) and acromioclavicular joint (SCJ and ACJ, respectively) are rare injuries in childhood/adolescence, each having its own special characteristics. In posterior SCJ dislocation, the concomitant injuries in the upper mediastinum are most important complication, while in anterior SCJ dislocation there is a risk of permanent or recurrent instability.

Methods

In a retrospective analysis from seven pediatric trauma centers under the leadership of the Section of Pediatric Traumatology of the German Trauma Society, children (<18 years) were analyzed with focus on age, gender, trauma mechanism, diagnostics, treatment strategy and follow-up results. Additional epidemiological big data analysis from routine data was done.

Results

In total 24 cases with an average age of 14.4 years (23 boys, 1 girl) could be evaluated (7x ACJ dislocation type ≥ Rockwood III; 17x SCJ dislocation type Allman III, including 12 posterior). All ACJ dislocations were treated surgically. Postoperative immobilization lasted 3–6 weeks, after which a movement limit of 90 degrees was recommended until implant removal. Patients with SCJ dislocation were posterior dislocations in 75%, and 15 of 17 were treated surgically. One patient had a tendency toward sub-dislocation and another had a relapse. Conservatively treated injuries healed without complications. Compared to adults, SCJ injuries were equally rarely found in children (< 1% of clavicle-associated injuries), while pediatric ACJ dislocations were significantly less frequent (p<0.001).

Conclusions

In cases of SCJ dislocations, our cohort analysis confirmed both the heterogeneous spectrum of the treatment strategies in addition to the problems/complications based on previous literature. The indication for the operative or conservative approach and for the specific method is not standardized. In order to be able to create evidence-based standards, a prospective, multicenter-study with a sufficiently long follow-up time would be necessary due to the rarity of these injuries in children. The rarity was emphasized by our routine data analysis.

Acromioclavicular and sternoclavicular joint dislocations indicate severe concomitant thoracic and upper extremity injuries in severely injured patients

Preliminary studies show that clavicle fractures (CF) are known as an indicator in the severely injured for overall injury severity that are associated with relevant concomitant injuries in the thorax and upper extremity. In this regard, little data is available for the rarer injuries of the sternoclavicular and acromioclavicular joints (SCJ and ACJ, respectively). Our study will answer whether clavicular joint injuries (CJI), by analogy, have a similar relevance for the severely injured. We performed an analysis from the TraumaRegister DGU (TR-DGU). The inclusion criterion was an Injury Severity Score (ISS) of at least 16. In the TR-DGU, the CJI were registered as one entity. The CJI group was compared with the CF and control groups (those without any clavicular injuries). Concomitant injuries were distinguished using the Abbreviated Injury Scale according to their severity. The inclusion criteria were met by n = 114,595 patients. In the case of CJI, n = 1228 patients (1.1%) were found to be less severely injured than the controls in terms of overall injury severity. Compared to the CF group (n = 12,030; 10.5%) with higher ISS than the controls, CJI cannot be assumed as an indicator for a more severe trauma; however, CF can. Concomitant injuries were more common for severe thoracic and moderate upper extremity injuries than other body parts for CJI. This finding confirms our hypothesis that CJI could be an indicator of further specific severe concomitant injuries. Despite the rather lower relevance of the CJI in the cohort of severely injured with regard to the overall injury severity, these injuries have their importance in relation to the indicator effect for thoracic concomitant injuries and concomitant injuries of the upper extremity. A limitation is the collective registration of SCJ and ACJ injuries as one entity in the TR-DGU. A distorted picture of the CJI in favor of ACJ injuries could arise from the significantly higher incidence of the ACJ dislocation compared to the SCJ. Therefore, these two injury entities should be recorded separately in the future, and prospective studies should be carried out in order to derive a standardized treatment strategy for the care of severely injured with the respective CJI.

Ultrasound Evaluation of Anterior Acromioclavicular Relationship in the Horizontal Plane on 40 Healthy Subjects. A New Possibility for Differential Diagnosis of Acromioclavicular Disjunctions Rockwood Stage 3 and 4? A Pilot Study

OBJECTIVE

To evaluate the repeatability and reproducibility of an ultrasound examination of the acromioclavicular joint (ACJ) performed by an orthopaedic surgeon to analyze anterior ACJ relationship in the horizontal plane.

DESIGN

Prospective observational study on healthy subjects.

SETTING

The study was conducted in 2017 in a university department of orthopaedic surgery and traumatology.

LEVEL OF EVIDENCE

III.

PATIENTS (OR PARTICIPANTS)

Forty consecutive volunteers aged 18 to 40 years were involved. INTERVENTIONS (OR ASSESSMENT OF RISK FACTORS OR INDEPENDENT VARIABLES):: The ultrasound examination was performed by 2 orthopaedic surgeons with a SonoSite M-Turbo portable ultrasound machine (Fujifilm, Japan). Distance measurement between the anterior edge of the clavicle (AECL) and the anterior edge of the acromion (AEAC) was done on the right side, then on the left one and repeated by the same examiner.

MAIN OUTCOME MEASURES

The intra- and interexaminer reproducibility of measurements was analyzed as primary outcome. Concordance of distance measurements between the right and left sides on the same subject was evaluated, as well as the "typical morphology" of the ACJ in the horizontal plane.

RESULTS

The intra- and interexaminer reproducibility for AECL-AEAC distance measurements was, respectively, 0.95 (0.93-0.97) and 0.87 (0.84-0.90). The correlation between the right and left sides was significant (P < 0.001), with a reproducibility of 0.86 (0.83-0.89). Twenty-seven (67.5%) volunteers were considered to have a "perfect alignment" of the AECL and AEAC.

CONCLUSIONS

This study confirms that it is possible to evaluate with good reproducibility the anterior AC relationship in the horizontal plane and that both sides are similar on the same subject.

Treatment of acromioclavicular joint separations in Japan: a survey

Background

Treatment options for acromioclavicular joint (ACJ) separations are highly dependent on severity, as well as the patient’s background. Furthermore, some patients can be switched from conservative to surgical treatment. In this study, we conducted a mail-based questionnaire survey of members of the Japan Shoulder Society on the administration of treatments for ACJ separations.

Methods

A questionnaire survey with 5 categories was mailed to all 1655 members of the Japan Shoulder Society (including 59 councilors): initial treatment, whether surgery was performed, indications for surgery based on severity, switching from conservative to surgical treatment, and surgical methods.

Results

Altogether, 183 members, including 56 councilors, responded. Regarding the initial treatment, 17 respondents opted for treatment without immobilization or fixation and 166 opted for immobilization or fixation. Of the members, 11 opted for only conservative treatment whereas 172 chose surgery depending on the case; of the latter, 9 considered it for patients with a Rockwood classification of type 2 or higher; 120, for patients with type 3 or higher; and 172, for patients with types 4-6. Furthermore, 75 of 172 members had experience switching to surgical treatment during conservative treatment. For 64 of 172 members, the modified Cadenat method was the most common surgical method.

Conclusions

Only 11 members opted for conservative treatment of ACJ separations, and approximately 95% of physicians chose surgery. Furthermore, >70% of physicians considered surgery for an injury classified as type 3 or higher, and 37% of members performed the modified Cadenat method. However, the popularization of arthroscopic surgery may affect the selection of surgical methods in the future.

Restoring Horizontal Stability of the Acromioclavicular Joint: Open Acromioclavicular Ligament Reconstruction and Repair With Semitendinosus Allograft

Injuries to the acromioclavicular (AC) joint are common and comprise ∼12% of shoulder injuries. Stability to the AC joint depends on the coracoclavicular (CC) ligaments for vertical stability and AC ligaments and capsular structures for horizontal stability. Injuries to the AC ligaments can lead to horizontal instability of the AC joint. There is no gold standard technique for treating these injuries surgically, and many of the described procedures focus on vertical instability rather than horizontal instability. This article describes an open AC ligament reconstruction with semitendinosus allograft to restore horizontal stability of the AC joint.

Editorial Commentary: Early Surgery and Restricted Rehabilitation Are Recommended for High-Grade Acromioclavicular Joint Dislocation

Despite acromioclavicular (AC) joint injuries being common, there are still controversies about the treatment; nonoperative versus surgical, who to operate, when to operate, which technique to use, and which rehabilitation protocol to use. Orthopaedic surgeons are often faced with these patients fearing not regaining normal function and to some degree acceptable cosmetic outcomes. Despite increasing interest in surgical management of type 3 AC joint injuries, surgical management has not been demonstrated to yield superior functional outcomes compared with nonoperative treatment. Interestingly, studies have demonstrated that good outcomes are achieved with most surgical techniques even though they are all associated with loss of initial reduction. This brings into question whether surgery is necessary in the early phase and how we can mitigate the effects of gravity to maintain reduction. Studies that can aid surgeons in patient selection for treatment protocols (nonoperative versus surgical) and timing of surgery are needed. We recommend early surgery, and restricted rehabilitation, for high-grade acromioclavicular joint dislocation.

Acromioclavicular Joint Separation: Repair Through Suture Anchors for Coracoclavicular Ligament and Nonabsorbable Suture Fixation for Acromioclavicular Joint

OBJECTIVE

To evaluate the clinical and radiographic outcomes of patients undergoing coracoclavicular (CC) ligament repair by two suture anchors and acromioclavicular (AC) joint (ACJ) fixation using heavy nonabsorbable sutures for the treatment of types III-V ACJ injuries with a minimum of 1-year follow-up.

METHODS

The clinical and radiographic outcomes of 36 consecutive patients (26 men and 10 women) who underwent anatomic reduction for acute ACJ dislocation using two suture anchors for CC ligament reconstruction and two strands of non-absorbable stitches for ACJ fixation between December 2013 and December 2018 were reviewed. Two 3.5 mm suture anchors with double-loaded sutures were separately inserted into the anterolateral and posteromedial portions of the coracoid process. The suture strands were passed through the hole created in the clavicle using 2.0 mm drill and tied over the clavicle. Additional ACJ augmentation using two strands of non-absorbable heavy sutures was performed in all patients. At 3, 6, and 12 months and last follow-up visit, the scores on the visual analog scale (VAS), the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, and simple shoulder test (SST) questionnaires were used to provide a final evaluation of shoulder function. Comparison between baseline and treatment results was performed. Radiographic analysis included vertical displacement and horizontal shift.

RESULTS

A total of 29 patients (20 men and nine women) were included in the study. A total of seven, six, and 16 patients had Rockwood type III, type IV, and type V ACJ dislocations, respectively. The mean patient age was 42.8 ± 13.5 years, with a mean follow-up of 28 months (range, 12-56 months). At the 12-month follow-up, the mean ASES score was 92.1 ± 3.5, with a mean pain score of 0.5 ± 0.7 on the VAS and mean Constant-Murley score of 93.0 ± 2.4. The new number of positive answers on the SST was 11.5 ± 0.6. Compared with the baseline, the clinical results improved significantly (P < 0.05). No significant difference could be found between the 6- and 12-month follow-up evaluations (P > 0.05). Radiographs showed two partial loss of reduction, whereas no horizontal displacement was found in all patients. One patient developed a superficial wound infection 3 weeks postoperation. The wound healed after routine wound care. No neurovascular complications were recorded.

CONCLUSIONS

CC ligament reconstruction using two suture anchors and ACJ augmentation using two strands of non-absorbable heavy sutures on high-grade AC dislocation is a reliable technique for restoring stability to the ACJ and can obtain good to excellent clinical results.

Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic

Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.

RR, Costa G, Verdalet I, Ezzeddine H, Rius X. Arthroscopically Assisted Comprehensive Double Cerclage Suture Fixation Technique for Acute Acromioclavicular Joint Separation

Acromioclavicular dislocations are some of the most frequently recorded and controversial injuries in the athletic population. These injuries have historically been a matter of disagreement between surgeons, particularly when it comes to the surgical technique used to treat them, its approach, or its timing. Consensus over the "gold standard" procedure to treat them is yet to be established. Even though numerous surgical techniques have already been described, the number of complications and loss of reduction remains a matter of concern for treating physicians. Here, we present an arthroscopically assisted coracoclavicular and horizontal acromioclavicular fixation technique in a modified figure-of-eight configuration using 2 strong FiberTape Cerclage sutures, with measurable tension, for the comprehensive treatment of acromioclavicular joint dislocations.

Early clinical and radiographic results of fixation with the TightRope device for Rockwood type V acromioclavicular joint dislocation: A retrospective review of 15 patients

OBJECTIVE

The aims of this study were, first, to assess the loss of reduction after fixation of Rockwood type V acromioclavicular joint dislocation (ACJD) with the TightRope device (Arthrex, Naples, FL, USA) and, second, to present the functional and radiological outcomes of this treatment.

METHODS

We retrospectively reviewed the medical records of 15 patients (12 males; mean age=39.2 years; age range=23-61) with Rockwood type V ACJD who were treated by the TightRope fixation device. The mean follow-up period was 19.3 (range=12-30) months. Functional status was assessed using the Constant-Murley score (CMS) at the final follow-up examination. To determine the reduction loss of ACJ, we measured and compared the coracoclavicular (CC) distance using radiographs with Zanca view in the early postoperative period and at the final follow-up examination. The fixation procedures were performed with an open technique using the TightRope fixation device.

RESULTS

The mean CMS at the final follow-up was 93.2 (range=82-100) points. All the patients experienced full recovery of the shoulder's range of motion, were able to return to the activities of daily living, and were satisfied with the treatment. ACJ reduction was successfully achieved in all the patients using the TightRope technique. Postoperative radiographs revealed no reduction loss in the ACJ, and the CC distance was well maintained. The mean CC distance was 19.95 (range=13.1-28.3) mm before surgery. The mean CC distance was 7.47 (range=4.2-11.5) mm in the early postoperative radiographic measurements. This difference was statistically significant (p=0.001). The mean CC distance at the final follow-up examination was 7.70 (range=4.5-11.7) mm. At the final follow-up visit, the shoulders of all the patients were still completely reduced, with a mean difference in the CC of 0.23 (range=0-1.3) mm compared with that in the early postoperative period. The difference in the CC between the early postoperative and final follow-up intervals was not statistically significant (p=0.055). No patient experienced recurrence or required an operation for hardware removal.

CONCLUSION

It seems that the TightRope device can provide anatomical restoration in patients with acute type V ACJD without subluxation at the final follow-up examination.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Imaging of the Acromioclavicular Joint: Anatomy, Function, Pathologic Features, and Treatment

The acromioclavicular joint is an important component of the shoulder girdle; it links the axial skeleton with the upper limb. This joint, a planar diarthrodial articulation between the clavicle and the acromion, contains a meniscus-like fibrous disk that is prone to degeneration. The acromioclavicular capsule and ligaments stabilize the joint in the horizontal direction, while the coracoclavicular ligament complex provides vertical stability. Dynamic stability is afforded by the deltoid and trapezius muscles during clavicular and scapular motion. The acromioclavicular joint is susceptible to a broad spectrum of pathologic entities, traumatic and degenerative disorders being the most common. Acromioclavicular joint injury typically affects young adult males and can be categorized by using the Rockwood classification system as one of six types on the basis of the direction and degree of osseous displacement seen on conventional radiographs. MRI enables the radiologist to more accurately assess the regional soft-tissue structures in the setting of high-grade acromioclavicular separation, helping to guide the surgeon's selection of the appropriate management. Involvement of the acromioclavicular joint and its stabilizing ligaments is also important for understanding and classifying distal clavicle fractures. Other pathologic processes encountered at this joint include degenerative disorders; overuse syndromes; and, less commonly, inflammatory arthritides, infection, metabolic disorders, and developmental malformations. Treatment options for acromioclavicular dysfunction include conservative measures, resection arthroplasty for recalcitrant symptoms, and surgical reconstruction techniques for stabilization after major trauma.

The Infinity-Lock System for Chronic Grade III AC Joint Dislocation: A Novel Technique, Rehabilitation Protocol and Short Term Results

Background: the choice of treatment of chronic grade III acromioclavicular (AC) joint dislocation is controversial. Several surgical techniques have been described in the literature, responding differently to nonoperative treatment. The aim of this study is to describe a modified technique of stabilizing an AC joint dislocation with the new Infinity-Lock Button System, in order to demonstrate that it is effective in optimizing outcomes and decreasing complications. Methods: this is a retrospective study of 15 patients who underwent surgical stabilization of the AC joint dislocation between 2018 and 2019, through modified surgical technique using the Infinity-Lock Button System. Active range of motion (ROM), Specific Acromio Clavicular Score (SACS) and Constant Score (CS) were evaluated preoperatively and postoperatively at last 18 months follow up. Patients rated their outcomes as very good, good, satisfactory, or unsatisfactory. Results: a total of twelve patients rated their outcome as very good and three as good; no patients were dissatisfied with surgery. The mean Constant Score increased from 38 points preoperatively to 95 postoperatively, the average SACS score decreased from 52 points preoperatively to 10 postoperatively, both significantly. No complications were detected. Conclusion: the described technique is effective for treatment of chronic grade III AC joint dislocation, resulting in elevated satisfaction ratings and predictable outcomes. Nevertheless, further longer term follow-up studies are required.

Posterior Rotational and Translational Stability in Acromioclavicular Ligament Complex Reconstruction: A Comparative Biomechanical Analysis in Cadaveric Specimens

BACKGROUND

Persistent posterior instability of the acromioclavicular (AC) joint is a reported complication after isolated coracoclavicular (CC) reconstruction. Thus, multiple techniques have been proposed attempting to restore biomechanics of the AC ligament complex (ACLC).

PURPOSE/HYPOTHESIS

The purpose was to evaluate the posterior translational and rotational stability of an ACLC reconstruction with a dermal allograft (ACLC patch) as compared with 3 suture brace constructs. It was hypothesized that the ACLC patch would better restore AC joint posterior stability.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 28 cadaveric shoulders (mean ± SD age, 57.6 ± 8.3 years) were randomly assigned to 1 of 4 surgical techniques: ACLC patch, oblique brace, anterior brace, and x-frame brace. The force and torque to achieve 10 mm of posterior translation and 20° of posterior rotation of the AC joint were recorded in the following conditions: intact, transected ACLC, ACLC patch/brace repair, ACLC patch/brace repair with dissected CC ligaments, and ACLC patch/brace repair with CC ligament repair.

RESULTS

For posterior translation, transection of the ACLC reduced resistance to 16.7% of the native. With the native CC ligaments intact, the ACLC patch (59.1%), oblique brace (54.1%), and anterior brace (60.7%) provided significantly greater stability than the x-frame brace (33.2%; P < .001, P = .008, P < .001, respectively). ACLC patch, oblique brace, and anterior brace continued to have significantly higher posterior translational resistance than the x-frame (35.1%; P < .001, P = .003, P < .001) after transection and subsequent CC ligament repair. For posterior rotation, transection of the ACLC decreased the resistance to 5.4% of the intact state. With the CC ligaments intact, the ACLC patch (77.1%) better restored posterior rotational stability than the oblique (35.3%), anterior (48.5%), and x-frame (23.0%) brace repairs (P < .001, P = .002, P < .001). CC ligament transection and subsequent repair demonstrated the ACLC patch (41.0%) to have improved stability when compared with the oblique (16.0%), anterior (14.0%), and x-frame (12.7%) repairs (P = .006, P = .003, P = .002).

CONCLUSION

ACLC reconstruction with a dermal allograft better restored native posterior rotational stability than other brace constructs, with translational stability similar to the oblique and anterior brace technique at the time of surgery.

CLINICAL RELEVANCE

Horizontal stability of the AC joint is primarily controlled by the ACLC. Inability to restore AC joint biomechanics can result in persistent posterior instability and lead to functional impairment.

Synthetic coracoclavicular ligament vs. coracoclavicular suspensory construct for treatment of acromioclavicular dislocation: a biomechanical study

BACKGROUND

A synthetic ligament (LockDown, Worcestershire, England) has become available to treat complete acromioclavicular dislocation with promising clinical results and potential benefit to avoid postoperative loss of reduction. We investigated the biomechanics of this synthetic ligament in a simulated immediate postoperative rehabilitation setting, hypothesizing that the synthetic ligament would demonstrate less superior coracoclavicular displacement to cyclic loading and higher ultimate load-to-failure values than a coracoclavicular suspensory construct.

METHODS

Seven matched-pair cadaveric shoulders (mean age at time of death, 79 years) were loaded cyclically and to failure. One specimen in each pair was randomly assigned to the synthetic ligament or coracoclavicular suspensory construct. Superiorly directed 70-N cyclic loading for 3000 cycles at 1.0 Hz was applied through the clavicle in a fixed scapula simulating physiologic states during immediate postoperative rehabilitation, followed by a load-to-failure test at 120 mm/min.

RESULTS

After 3000 cycles, the superior displacement of the clavicle in the synthetic ligament (9.2 ± 1.1 mm) was 225% greater than in the coracoclavicular suspensory construct (2.8 ± 0.4 mm, 95% confidence interval [CI] 3.4, 8.3; P < .001). Average stiffness of the synthetic ligament (32.8 N/mm) was 60% lower than that of the coracoclavicular suspensory construct (81.9 N/mm, 95% CI 43.3, 54.9; P < .001). Ultimate load-to-failure of the synthetic ligament was 23% (95% CI 37.9, 301.5; P = .016) lower than the coracoclavicular suspensory construct (580.5 ± 85.1 N and 750.2 ± 135.5 N, respectively).

CONCLUSION

In a simulated immediate postoperative cadaveric model, the synthetic ligament demonstrated poorer biomechanics than the coracoclavicular suspensory construct. These findings suggest that a coracoclavicular suspensory construct may be preferable to a synthetic ligament if early rehabilitation is intended.

Systematic review of the treatment of acromioclavicular joint disruption comparing number of tunnels and graft type

BACKGROUND

The management of high-grade acromioclavicular separations remains unclear. The surgical interventions have shifted to more anatomic, less invasive techniques. The purpose of this study was to systematically review the outcomes and complications of anatomic coracoclavicular ligament reconstruction using a tendon graft.

METHODS

Twenty-one studies (n = 460 patients) met the criteria for inclusion. A double clavicle tunnel tendon graft construct was used in 348 patients (75.7%), whereas a single clavicle tunnel technique was used in 112 patients (24.3%). No significant difference in loss of reduction was found between the 2 techniques. Of 460 patients, 96 (20.9%) demonstrated some form of radiographic displacement at the final follow-up. The overall complication rate was 21.3% (98 of 460), and a higher complication rate was found in the double clavicle tunnel technique (P < .001). The overall reoperation rate was 7.6% (37 of 460). The most common reason for reoperation was clavicle fracture (8 of 37). There was a statistically significant increase in reoperation when allograft was used (P = .003).

CONCLUSION

The results of this study suggest that despite newer techniques, approximately 20% of patients develop loss of reduction and/or experience a surgical complication. Attempts to minimize trauma to the clavicle and use autograft tendon may reduce the risk of reoperation.

Current practice in the management of acromioclavicular joint dislocations; a national survey in the Netherlands

Purpose

The aim of this study was to investigate current practice in the management of acromioclavicular joint dislocations in the Netherlands.

Methods

A 36-item literature-based and expert consensus survey was developed. If available, one orthopaedic and one trauma surgeon for every hospital (n = 82) in the Netherlands was asked to complete the online questionnaire. Only complete data sets were included in the analysis. Descriptive analysis was performed using SPSS.

Results

Of 149 invited surgeons, 106 (71%) fully completed the survey. The diagnosis of ACJ injury was mainly based on physical examination (91%) and radiographs (95%). The vast majority of patients with ACJ injuries was treated non-operatively. The decision for operative treatment was mainly based on the surgeon’s experience and available literature. Patient-related factors that contributed most to the decision to operate or not, were mainly functional needs and age. Cosmesis and gender contributed less to this decision. Rockwood II and III ACJ injuries were usually treated non-operatively, whereas Rockwood IV and V ACJ injuries were usually treated operatively. For primary and secondary operative treatment, a flexible implant was preferred over rigid fixation techniques. All respondents agreed that nonoperative treatment of Rockwood II ACJ injuries leads to satisfactory results and that secondary operative treatment is only rarely required. Also the majority of patients with Rockwood III ACJ injuries is treated non-operatively, although failure rates are considered higher.

Conclusion

This survey showed a significant individual variation on diagnosis and treatment strategies among surgeons in the Netherlands. The majority of the Dutch surgeons concern a flexible implant the best available technique for patients who require operative treatment.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01414-0) contains supplementary material, which is available to authorized users.

Time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the COVID-19 pandemic

Purpose

Timing of surgery for orthopaedic injuries continues to evolve, as an improved understanding of biology, healing, and technological advances continues to challenge historical norms. With the growing COVID-19 pandemic stretching limited healthcare resources, postponing surgery becomes an inevitable and unenviable task for most orthopaedic surgeons, and a shift in outpatient paradigms is required to mitigate poor outcomes in patients.

Methods

A scoping review of five databases on surgical timing and orthopaedic soft-tissue injuries was performed. All randomized controlled trials, longitudinal cohort studies, retrospective case series, systematic reviews, meta-analyses, and expert opinions were included for review, with 65 studies meeting the inclusion criteria.

Results

Better outcomes appear to be associated with early surgery for subluxations (< 1 week), recurrent dislocations (> 2 episodes), ligamentous and tendinous injuries (< 2 weeks), and bony avulsion injuries (< 3 weeks). Spinal conditions with neurological compromise should be operated on within 24 hours and spinal instability within 72 hours to reduce the risk of complications and poor outcomes.

Conclusion

Most soft-tissue orthopaedic injuries can be managed with outpatient ambulatory surgery in a semi-elective setting. As the paradigm for outpatient surgery shifts due to technological advances and the COVID-19 pandemic, it is critical for surgeons to time their surgery appropriately to maintain the high standards of orthopaedic practice.

The frequency of reduction loss after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device, and its effect on clinical and radiological results

Background

The aim of this study was to investigate the effect of reduction loss of more than 3 mm on clinical and radiological results after at least 2 years of follow-up after arthroscopic fixation of acute acromioclavicular joint dislocations using a double-button device.

Methods

Thirty-six patients who had acute (< 3 weeks old), type III or V acromioclavicular (AC) joint dislocations underwent arthroscopic fixation of the AC joint using a double-button device. Clinical and radiological evaluations were performed at preoperative, postoperative first day, 3 months and last follow-up. When the coracoclavicular (CC) distances of patients at the last follow-up were compared to the early postop CC distances, those with a difference of 3 mm or less were grouped as group A and those with a difference of more than 3 mm were grouped as group B.

Results

There was no statistically significant difference between the groups in terms of age, gender, follow-up time, time from injury to surgery, return to work, and distribution of Rockwood classification. Pre-operative CC distance was reduced from 18.7 ± 3.5 to 8.5 ± 0.6 in the early postoperative period. Anatomic reduction was achieved in all patients compared with the unaffected side (CC distance 8.6 ± 0.7). However, the CC distance increased to 9.9 ± 1.5 at the third-month follow-up and increased to 11 ± 2.7 at the last follow-up. There were no significant Constant score differences between the groups in the preoperative and last follow-up periods (p > 0.05). At the last follow-up, the mean Acromioclavicular Joint Instability (ACJI) score of group A was 84.4 ± 8, whereas it was 68.3 ± 8.3 for group B, and the difference was statistically significant (p < 0.01). Furthermore, the subjective evaluation and aesthetic subjective satisfaction values of group B were lower than group A (p < 0.01).

Conclusions

Reduction loss of more than 3 mm was observed in 25% of patients after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device. Although this loss did not create a statistically significant difference in Constant scores, AC joint-specific tests such as ACJI, subjective evaluation, and aesthetic subjective satisfaction values were significantly impaired.

Modified Weaver-Dunn Procedure for Type 3 Acromioclavicular Joint Dislocation: Functional and Radiological Outcomes

Background

Controversy surrounds the indication for treatment of type 3 acromioclavicular joint dislocation, and the optimal reconstructive technique has not yet been defined. Since the first description of the Weaver-Dunn procedure, several studies have described the clinical and radiological results that can be expected postoperatively; however, few studies have evaluated the outcomes of this technique for chronic type 3 acromioclavicular joint dislocation.

Purpose/Hypothesis

The purpose of this study was to evaluate the functional and radiographic mid- to long-term outcomes of a modified Weaver-Dunn procedure for chronic Rockwood type 3 acromioclavicular joint dislocation. We hypothesized that (1) functional outcomes comparable with sex- and age-matched healthy individuals could be achieved with the modified Weaver-Dunn procedure and (2) joint stability could be restored after surgery.

Study Design

Case series; Level of evidence, 4.

Methods

Out of 30 patients who sustained a chronic type 3 acromioclavicular joint dislocation, 27 had a minimum 12-month follow-up and were included in the study. All patients underwent a modified Weaver-Dunn procedure. The Constant-Murley score was used to assess patient postoperative function. Subjective evaluation of patient satisfaction with surgery was also recorded. Radiological assessment was performed postoperatively to evaluate superoinferior and anteroposterior joint stability.

Results

After a mean follow-up period of 51.6 months, the mean Constant-Murley score was 90.1, which was 97.2% that of a group of sex- and age-matched healthy individuals. In the multivariate analysis, higher Constant-Murley score was associated with male sex (β = 0.385; P = .043) and higher subjective satisfaction scale (β = 0.528; P = .003). All patients returned to their previous work and sport activity levels having high satisfaction with surgery. Successful vertical acromioclavicular joint reduction was obtained in all but 1 patient; however, horizontal joint stability was not completely restored with the modified Weaver-Dunn procedure. No intraoperative complications occurred, and the postoperative complication rate was 7.4%.

Conclusion

In patients with chronic type 3 acromioclavicular joint dislocation, the modified Weaver-Dunn procedure is an effective technique to restore vertical but not horizontal joint stability 4 years after surgery. High levels of satisfaction with surgery and functional outcomes comparable with sex- and age-matched healthy individuals can be achieved.

Comparison between Trans-articular and Subacromial Stabilization with Ligament Repair for Acute Acromioclavicular Dislocation

Background:

Although numerous treatment options for acromioclavicular joint dislocation have been reported, the treatment strategy is not yet standardized.

Objective:

The purpose of this study was to evaluate the clinical and radiographic results of coracoclavicular ligament repair with temporary acromioclavicular stabilization using suture anchors and Kirschner wires, and to compare the results between temporary trans-articular fixation and subacromial stabilization of the acromioclavicular joint.

Methods:

Thirty-three cases with displaced acromioclavicular joint dislocation were retrospectively evaluated. In the first 14 cases, the wires temporarily penetrated the joint for an average of 7 weeks (trans-articular group), while the acromioclavicular joint was temporarily stabilized by wires passing under the acromion that were inserted into the distal clavicle for an average of 13 weeks in the latter 19 cases (subacromial group). Clinical and radiographic results were evaluated and compared between the two groups.

Results:

The average UCLA score was 32.0 points in the trans-articular group and 32.8 points in the subacromial group, indicating no difference between the two groups (P = 0.418). Coracoclavicular distance ratio after surgery was significantly smaller in the subacromial group (P ≤ 0.035), and acromioclavicular dislocation ratio after removal of the wires was also smaller in the subacromial group (P ≤ 0.001) compared with the trans-articular group.

Conclusion:

This study revealed that coracoclavicular ligament repair with temporary acromioclavicular stabilization leads to favorable clinical results, with the subacromial group showing better maintenance of joint reduction compared with the trans-articular group. Subacromial wire stabilization is a viable option for long-term temporary fixation of acute displaced acromioclavicular joint dislocation.

Surgical treatment of acute Rockwood III acromioclavicular dislocations-Comparative study between two flip-button techniques

Acromioclavicular joint dislocation is a common shoulder injury, usually caused by direct violence on the shoulder. Optimal treatment of type III is still a hot discussion currently in orthopedic surgeons. With the advent of many flip-button techniques, Tightrope system and Endobutton system become popular techniques for reconstruction of coracoclavicular ligaments. The purpose of the study was to compare the clinical and radiological results between the two techniques. A retrospective case-control study was conducted in 60 patients with acute Rockwood III acromioclavicular joint dislocation. The two techniques conducted were open procedures using Twin Tail Tightrope system (Group A, n = 30) and Endobutton system (Group B, n = 30). 60 patients were followed up at least two years. Surgical parameters including incision length, operation time and operative blood loss were analyzed. Functional outcomes were evaluated using the Constant-Murley Score. Radiological results were assessed based on coracoclavicular distance preoperatively, one day postoperatively, and at the final follow-up. 60 patients were followed up for at least 24 months (range 24 to 32). The incision length and operation time were shorter in Group A than that in Group B. The blood loss of surgery was significantly less in the Group A. There were no significant differences between the two groups regarding the Constant-Murley Score at the final follow-up. No significant differences were found in the coracoclavicular distance preoperatively, immediately postoperatively, and at the final follow-up. Both techniques offered satisfying functional outcomes, however the Tightrope system provided better surgical parameters.

Optimal Management of Acromioclavicular Dislocation: Current Perspectives

Injuries to the acromioclavicular (AC) joint are common and mostly involve younger, male individuals. Whereas the majority of AC joint dislocations can be treated nonoperatively with a trial of immobilization, pain medication, cryotherapy, and physiotherapy, there are patients that do not respond well to conservative management and may require surgical treatment. Identifying and treating these patients according to the type and chronicity of AC joint dislocation is paramount. To date, a myriad of surgical techniques have been proposed to address unstable AC joint dislocations and are indicative of the uncertainty that exists in optimal management of these injuries. Historically research has focused on the restoration of the coracoclavicular ligament complex. However, recently the importance of the acromioclavicular capsule and ligaments has been emphasized. This review aims to provide the reader with an overview of current treatment strategies and research, as well as future perspectives.

Comparison of two methods for coracoclavicular ligament reconstruction: A finite element analysis

OBJECTIVE

This study aimed to compare two different tendon grafting techniques for coracoclavicular ligament reconstruction from the data obtained using finite element analysis.

METHODS

Three different finite element models of the shoulder girdle were formulated using computerized tomography images: the reference model, coracoid loop technique (CLT), and drilling technique (DT) model. In all these models, forces were applied to the clavicle along three axes (x, y, and z) of the trapezius and sternocleidomastoid muscles. Thereafter, data regarding the loading values of the tendon grafts, loads on the coracoid base, and coracoclavicular vertical distance were measured.

RESULTS

While the reference model yielded the lowest values for all the loading conditions as well as the shortest coracoclavicular distance, the DT model demonstrated the highest values for all the loading conditions and the largest coracoclavicular distance.

CONCLUSION

Different tendon grafting techniques may offer different loading values on both bone surface and tendon graft during coracoclavicular ligament reconstruction. The drilling technique may be associated with increased loading on the tendon graft and bone surface, causing further loss of reduction and consequent complications.

Radiological study of the Asian coracoid process and clavicle: Implications for coracoclavicular ligament reconstruction

PURPOSE

Iatrogenic coracoid and clavicle fracture is a known complication of drilling bone tunnels during anatomic coracoclavicular ligament reconstruction (ACCR). This study aims to measure the dimensions of coracoid process and clavicle in an Asian population to evaluate the suitability of drilling coracoid and clavicle tunnels for ACCR in Asians.

METHODS

Width measurements of 196 coracoids and 189 clavicles were obtained after reviewing all computed tomography (CT) scans of the shoulder performed over a 6 years period. Coracoid measurements were made on the CT slice which showed the maximum cross sectional width of the coracoid base. Medial to lateral measurements of the coracoid width were taken on an axial view, 4 mm above the identified junction of the coracoid base and glenoid base. Antero-posterior clavicle width was measured through a point directly above the midpoint of the coracoid and perpendicular to the long axis of the clavicle.

RESULTS

The overall mean coracoid width was 14.8 mm ± 2.54 mm (range 9.2-23.3 mm) and clavicle width was 17.1 mm ± 2.72 mm (range 11.1-25.3 mm).

CONCLUSION

The Asian coracoid process is smaller than its Western equivalent. More research is required to validate this conclusion as no cadaveric studies with equivalent measurement techniques have been performed on Asians. Given the potentially narrower dimensions of the Asian coracoid process, extra precautions are required to minimize the risk of iatrogenic coracoid and clavicle fractures.

The Relationship Between the Clinical and Radiological Findings and the Outcomes of Early Surgical Treatment After Tossy Type III Acromioclavicular Joint Dislocation

Background

Acromioclavicular joint (ACJ) dislocation is a common injury among young and physically active persons. Evaluating surgical outcomes clinically and radiographically is widely accepted, but it is not known which clinical tests or radiological indicators are the most important. Our hypothesis is that there is a significant correlation between clinical and radiological findings and outcomes after the early surgical treatment of Tossy type III ACJ dislocation. 

Materials and methods

A retrospective study was conducted on 23 patients who underwent early surgical treatment after Tossy type III ACJ dislocation. We used the constant score (CS) and the simple shoulder test (SST) to measure the outcomes. For clinical evaluation, Paxinos, O’Brien’s, Bell-van Riet’s, and horizontal adduction tests were used. Standard A-P view radiographs were evaluated for redislocation, ACJ arthrosis, coracoclavicular (CC) space ossification, and for the presence of osteolysis.

Results

The mean time of follow-up was 16 months (range, 12-22 months). During the follow-up, all patients had one or more pathological radiological signs. All clinical tests were negative in 12 patients, seven had one positive test, three had two positive tests, and one had three positive tests. The mean CS result at the follow-up was 93.44 ± 4.90 (range, 84-100), and the mean SST result was 10.78 ± 1.51 (range, 6-12). There was no statistically significant association between the CS results and either shoulder tests or radiological findings. The SST results were statistically significantly lower for patients with positive O’Brien’s test compared to those with a negative one. In contrast, the SST results were statistically significantly higher for patients with CC space ossification, compared to those who did not have this radiological sign. Other clinical tests and radiological findings did not have any associations with the SST results.

Conclusions

We found that positive O’Brien’s test was associated with worse outcomes of early surgical treatment after Tossy type III ACJ dislocation. Despite the presence of pathological radiological signs, patients may have good or even perfect clinical outcomes after the early surgical treatment of a Tossy type III injury.

Arthroscopic Coracoclavicular Ligament Reconstruction of Chronic Acromioclavicular Dislocations Using Autogenous Semitendinosus Graft: A Two-Year Follow-up Study of 58 Patients

Purpose

To determine the results of operatively treated chronic acromioclavicular (AC) joint dislocations after 2-year follow-up.

Methods

Fifty-eight patients with chronic acromioclavicular separations underwent arthroscopic coracoclavicular ligament reconstructions using semitendinosus autografts. Constant and Simple Shoulder Test scores were determined before and 2 years after surgery as a part of standard clinical practice. General patient satisfaction with the outcome (poor, fair, or excellent) also was assessed. In addition, for purposes of routine clinical follow-up, the coracoclavicular distance was measured from the inferior cortex of the clavicle to the superior cortex of the coracoid using anteroposterior radiographs taken 2 years after surgery. The results were compared with postoperative radiographs and changes in the distance were recorded. The clavicular drill hole was similarly measured 2 years after surgery to detect possible tunnel widening.

Results

The mean preoperative Constant score increased from a preoperative mean of 52.6 ± 16.5 to 94.7 ± 7.9 at 2 years postoperatively (P = .000). The Simple Shoulder Test score increased from a preoperative mean of 7.7 ± 1.64 to 11.8 ± 0.7 (P = .000). The mean coracoclavicular distance increased from 10.5 ± 3.4 to 12.4 ± 3.9 mm (P = .009). The diameter of the clavicular drill hole increased from 6.0 mm to a mean of 8.4 mm. Two coracoid fractures were observed, but no clavicular fractures. One patient experienced a deep infection, leading to total reconstruction failure, and 2 patients had superficial postoperative infections. Forty-five patients (85%) reported excellent subjective outcomes, and 8 (15%) reported a fair outcome.

Conclusions

The outcomes of this series of coracoclavicular ligament reconstruction were favorable and the number of serious complications was small. However, clavicular wound issues were a significant problem. Coracoclavicular ligament reconstruction is a challenging procedure, but satisfactory results can be achieved with careful patient selection and good technique.

Level of Evidence

Level IV, therapeutic case series

What Outcome Measures Are Reported in the Management of Acromioclavicular Joint Injuries?

Background

Lack of uniformity in reported outcomes makes comparisons between acromioclavicular joint (ACJ) injury studies challenging. Knowledge of common outcome measures and standardization will help orthopaedic surgeons report and compare outcomes more consistently.

Purpose

To identify the most commonly reported outcome measures for ACJ injuries.

Study Design

Systematic review.

Methods

A systematic review was performed to identify all English-language original articles assessing any type of management of ACJ injuries (acute and chronic) in PubMed and Scopus from 2007 to 2017. Review articles, meta-analyses, studies with less than 5 patients, pediatric studies, technique articles, and biomechanical studies were excluded. The 100 top orthopaedic journals in the English literature were selected for review. Included studies were assessed for patient characteristics and the use of outcome variables, including range of motion (ROM), strength, patient-reported outcomes (PROs), satisfaction, return to work, return to sport, and complications.

Results

A total of 605 unique articles were identified; 92 met the inclusion criteria. The average number of ACJ injuries per study was 37, with a mean weighted patient age of 36 years (range, 20.1-57.3 years). The mean follow-up was 36 months (range, 5-290 months). Acute injuries were reported in 59% of studies. ROM and strength measurements were reported in 22.8% and 5.4% of studies. Sixteen different PRO instruments were used. The most commonly reported measures were Constant score (75%), visual analog scale for pain (VAS-pain; 33%) score, American Shoulder and Elbow Surgeons (ASES) score (21%), Simple Shoulder Test (SST) score (19%), and University of California Los Angeles (UCLA; 17%) shoulder score. An average of 2.5 outcome measures per study were reported. The use of 4 or more outcome scores was associated with publication in higher-impact factor journals.

Conclusion

Inconsistent reporting of multiple outcome measures is present in the ACJ injury literature. The best scoring system for assessing ACJ injury and treatment has not yet been agreed upon. Until improved scoring systems come into general use, we recommend that future literature on ACJ injuries use at least 4 outcome scores and include the commonly used outcome measures (Constant, VAS-pain, ASES, and SST scores) to enable future comparison of patient outcomes across publications.

Reconstruction of the Acromioclavicular Ligament Complex Using Dermal Allograft: A Biomechanical Analysis

PURPOSE

To analyze the posterior translational and rotational stability of the acromioclavicular (AC) joint following reconstruction of the superior acromioclavicular ligament complex (ACLC) using dermal allograft.

METHODS

Six fresh-frozen cadaveric shoulders were used (mean age of 65.3 ± 6.9 years). The resistance force against posterior translation (10 mm) and torque against posterior rotation (20°) was measured. Specimens were first tested with both the intact ACLC and coracoclavicular ligaments. The ACLC and coracoclavicular ligaments were then transected so simulate a Type III/V AC joint dislocation. Each specimen then underwent 3 testing conditions, performed in the following order: (1) ACLC patch reconstruction alone, (2) ACLC patch with an anatomic coracoclavicular reconstruction (ACCR) using semitendinosus allograft, and (3) the transected ACLC with an ACCR only. Differences in posterior translational and rotational torque across testing conditions were analyzed with a one-way repeated analysis of variance analysis.

RESULTS

Mean resistance against posterior translation in the intact condition was 65.76 ± 23.8 N. No significant difference found between the intact condition compared with specimens with the ACLC-patch only (44.2 ± 11.3 N, P = .06). The ACCR technique, when tested alone, had significantly less posterior translational resistance compared with the intact condition (38.5 ± 8.94 N, P = .008). ACLC patch in combination with an ACCR was closest in restoring native posterior translation (57.1 ± 19.2 N, P = .75). For rotational resistance, only the addition of the ACLC patch with an ACCR (0.51 ± 0.07 N-m) demonstrated similar torque compared with the intact joint (0.89 ± 0.5 N-m, P = .06).

CONCLUSIONS

The ACLC-patch plus ACCR technique was able to closest restore the percent of normal posterior translational and rotational stability.

CLINICAL RELEVANCE

Recurrent posterior instability of the AC joint is a potential complication after coracoclavicular reconstruction surgery. In the in vitro setting, this study demonstrated increased AC joint stability with the addition of an ACLC reconstruction using dermal allograft.

Surgical treatment of acute and chronic AC joint dislocations: Five-year experience with conventional and modified LARS fixation by a single surgeon

BACKGROUND

Different surgical fixation methods are available for the treatment of acromioclavicular (AC) joint dislocations. The aim of this study was to present the results of five years of experience with the Ligament Augmentation and Reconstruction System (LARS) fixation technique by a single surgeon.

METHODS

A single-center retrospective cohort study was performed. All patients treated for an AC joint dislocation with LARS fixation by the same surgeon between 2012 and 2016 (n = 20) were eligible for inclusion. All these dislocations were unstable injuries, Rockwood type-III or higher, requiring acute or chronic repair. The primary outcome was the QuickDASH score. Secondary outcomes were the Subjective Shoulder Value (SSV), Numerical Rating Scale (NRS) pain score, return to work, complications, and implant removal.

RESULTS

17 patients (85%) were available for final follow-up. The median follow-up was 23 months (IQR; 17─34). The median QuickDASH score was 7 (IQR; 2-18), the median SSV was 90 (IQR; 80-90), and the median NRS pain score was 2 (IQR; 1-3). Patients returned to work after a median of 8 weeks (IQR; 6-12). There was no significant difference in functional outcome scores between acute and chronic repair, or between the conventional and modified LARS fixation groups. There were two major complications requiring revision surgery, one ruptured LARS ligament and one case of deep wound infection. Implant removal was performed in one patient.

CONCLUSIONS

The LARS ligament fixation technique seems to be effective for the treatment of AC joint dislocations, resulting in good short- and mid-term patient-reported functional outcome. LARS fixation might also be an acceptable treatment option for active patients with symptomatic chronic AC dislocations.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study, Treatment Study.

Anatomic and non-anatomic reconstruction improves post-operative outcomes in chronic acromio-clavicular instability: a systematic review

PURPOSE

To systematize the surgical outcomes of anatomic and non-anatomic reconstruction in patients with chronic acromio-clavicular joint (ACJ) instability and determine which technique is superior.

METHODS

This review was conducted according to the PRISMA guidelines. PubMed and Cochrane Library databases were searched up to April 30th, 2018 for original articles that assessed the outcomes of one or more surgical techniques of anatomic and non-anatomic reconstruction in patients with chronic ACJ instability. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Pre-to-post meta-analysis was performed for both anatomic and non-anatomic reconstructions.

RESULTS

Twenty-eight studies were included comprising 799 patients (mean age of 36.6 years old and 84% males) with a mean follow-up of 34.6 months (range 13 to 74). Surgical techniques included anatomic (tendinous or synthetic grafts/constructs) and non-anatomic reconstruction (Weaver-Dunn or Modified Weaver-Dunn, conjoined tendon transfer, or temporary hook plate). There were significant pre-to-post improvements on the constant score with an average improvement ranging from 11.1 to 50.7 (p < 0.01). Average failure rate was 7.6% (7.5% for anatomic and 8.5% for non-anatomic reconstruction). Non-comparative studies had a mean MINORS score of 9 points (out of 16) and comparative studies 17 (out of 24) with excellent interrater agreement (k = 0.910).

CONCLUSION

Both anatomic and non-anatomic ACJ reconstructions provide significant post-operative improvements, but definitive conclusions on optimal technique remain elusive. Notwithstanding, comparative studies support the use of anatomic ACJ reconstruction which should be preferably used. However, until superiority is demonstrated by robust studies, surgeons should supplement their decision-making with experience and patient preference.

LEVEL OF EVIDENCE

IV.

Repair of the entire superior acromioclavicular ligament complex best restores posterior translation and rotational stability

PURPOSE

The acromioclavicular ligament complex (ACLC) is the primary stabilizer against horizontal translation with the superior ACLC providing the main contribution. The purpose of this study was to evaluate the specific regional contributions in the superior half of ACLC, where the surgeon can easily access and repair or reconstruct, for posterior translational and rotational stability.

METHODS

The superior half of ACLC was divided into three regions; Region A (0°-60°): an anterior 1/3 region of the superior half of ACLC, Region B (60°-120°): a superior 1/3 region of the superior half of ACLC, and Region C (120°-180°): a posterior 1/3 region of the superior half of ACLC. Fifteen fresh-frozen cadaveric shoulders were used. Biomechanical testing was performed to evaluate the resistance force against passive posterior translation (10 mm) and the resistance torque against passive posterior rotation (20°) during the following the four conditions. (1) Stability was tested on all specimens in their intact condition (n = 15). (2) The ACLC was dissected and stability was tested (n = 15). (3) Specimens were randomly divided into three groups by regions of suturing. Stability was tested after suturing Region A, Region B, or Region C (n = 5 per group). (4) Stability was tested after suturing additional regions: Region A + B (0°-120°), Region B + C (60°-180°), or Region A + C (0°-60°, 120°-180°, n = 5 per group).

RESULTS

The translational force increased after suturing Region A when compared with dissected ACLC (P = 0.025). The force after suturing Region A + B was significantly higher compared to the dissected ACLC (P < 0.001). The rotational torque increased after suturing Region A or Region B compared with dissected ACLC (P = 0.020, P = 0.045, respectively). The torque after suturing the Region A + C was significantly higher compared to the dissected ACLC (P < 0.001).

CONCLUSION

The combined Region A + B contributed more to posterior translational stability than Region B + C or Region A + C. In contrast, combined Region A + C contributed more to posterior rotational stability than Region A + B or Region B + C. Based on these findings, surgical techniques restoring the entire superior ACLC are recommended to address both posterior translational and rotational stability of the AC joint.

The importance of biomechanical properties in revision acromioclavicular joint stabilization: a scoping review

PURPOSE

Treatment of failed primary reconstruction of the unstable acromioclavicular (AC) joint remains challenging for orthopaedic surgeons. When approaching revision cases, the reason for failure has to be precisely identified. The purpose of this manuscript was to perform a critical review of the literature regarding treatment options for failed AC joint stabilization techniques and to provide a treatment algorithm for salvage procedures.

METHODS

A thorough search included electronic databases for articles published up to April 15th, 2019. Inclusion criteria were set as (1) studies that reported on clinical outcomes following surgical or conservative treatment of AC joint dislocation; (2) studies reporting on failure or complications of primary treatment; (3) chronic instabilities caused by delayed or secondary treatment as well as (4) revision and salvage procedures.

RESULTS

The search strategy identified a total of 3269 citations. The final dataset comprised 84 studies published between 1954 and 2019. A total of 5605 patients (9.63% females) were involved with a mean age of 34.5 years. Overall, complication rates varied between 5 and 88.9% in patients with AC joint instability.

CONCLUSION

In the current literature, evidence for treatment of revision AC joint instability is still lacking, however, surgical treatment continues to evolve. The importance of failure analysis and clinically relevant algorithms were highlighted in this review. Adequately restoring native joint biomechanics is needed for ensuring an optimal healing environment that will translate into patient satisfaction and long-term stability.

LEVEL OF EVIDENCE

V.

Arthroscopically assisted acromioclavicular joint stabilization leads to significant clavicular tunnel widening in the early post-operative period

PURPOSE

Arthroscopically assisted acromioclavicular joint (ACJ) stabilization techniques use bone tunnels in the clavicle and coracoid process. The tunnel size has been shown to have an impact on the fracture risk of clavicle and coracoid. The aim of the present study was to radiographically evaluate the alterations of the clavicular tunnel size in the early post-operative period. It was hypothesized that there would be a significant increase of tunnel size.

METHODS

Twenty consecutive patients with acute high-grade ACJ (Rockwood type IV-V) injury underwent arthroscopic-assisted ACJ stabilization. The median age of the patients was 40 (26-66) years. For all patients, a single tunnel button-tape construct was used along with an additional ACJ tape cerclage. Radiologic measurements were undertaken on standardized Zanca films at two separate time points, immediate post-operative examination (IPO) and at late post-operative examination (> 4 months; LPO). The LPO radiographs were taken at a median follow-up period of 4.5 (3-6) months. Clavicular tunnel width (CT) and coracoclavicular distance (CCD) were measured using digital calipers by two independent examiners and the results are presented as median, range, and percentage.

RESULTS

The median CCD increased significantly from 9.5 (8-13) mm at IPO to 12 (7-20) mm at LPO (p < 0.05). Median tunnel size showed significant difference from 3 (3-4) mm at IPO to 5 (4-7) mm at LPO (p < 0.05). Despite a significant increase of 2 mm (66.6%) of the initial tunnel size, there was no correlation between tunnel widening and loss of reduction.

CONCLUSION

Arthroscopic ACJ stabilization with the use of bone tunnels led to a significant increase of clavicular tunnel size in the early post-operative period. This phenomenon carries a higher fracture risk, especially in high-impact athletes, which needs to be considered preoperatively.

LEVEL OF EVIDENCE

IV.

Clavicle and coracoid process periprosthetic fractures as late post-operative complications in arthroscopically assisted acromioclavicular joint stabilization

PURPOSE

Arthroscopic-assisted stabilization surgery for acute acromioclavicular joint (ACJ) disruption shows excellent and reliable clinical outcomes. However, characteristic complications such as fracture of the clavicle and coracoid have been reported to occur during the early post-operative period. The main goal of this study was to highlight the occurrence of fractures as a late post-operative complication. The secondary goals were to describe possible fracture morphologies and treatment outcomes.

METHOD

Patient records from a single surgery centre were searched for all patients presenting with late fracture complication following arthroscopically assisted acromioclavicular stabilization. Medical reports including the operative notes and pre- and post-operative X-rays were reviewed. A telephone interview was conducted with each patient to access the American Shoulder and Elbow Surgeons shoulder score.

RESULTS

A total of four patients presented with late fracture complication following arthroscopic-assisted ACJ stabilization surgery. All patients were males and presented following trauma at a median duration of 19.5 months after the index surgery. Fracture morphology differed between patients; the treatment was conservative in three patients, while one patient underwent osteosynthesis.

CONCLUSION

Traumatic peri-implant fractures can occur, even 2 years after arthroscopically assisted ACJ reconstruction. This needs to be considered when planning for surgical intervention in acute ACJ disruption, especially in a high-risk population.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Functional and Radiographic Outcomes After Anatomic Coracoclavicular Ligament Reconstruction for Type III/V Acromioclavicular Joint Injuries

Background

Acromioclavicular (AC) joint separation is a common injury. The anatomic coracoclavicular ligament reconstruction (ACCR) technique is a viable treatment option, designed to restore the native joint anatomy.

Purpose

To evaluate the clinical and radiographic outcomes of patients undergoing ACCR for the treatment of type III and V AC joint injuries with a minimum 2-year follow-up.

Study Design

Case series; Level of evidence, 4.

Methods

A retrospective chart review was performed on prospectively collected data. Patients who underwent ACCR for type III or V AC joint injuries between January 2003 and December 2015 were analyzed. Clinical outcome measures included the American Shoulder and Elbow Surgeons (ASES) score, Rowe score, Simple Shoulder Test (SST), and Constant-Murley (CM) score. To determine the clinical relevance of the ASES score, the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were used. The pre- and postoperative coracoclavicular distance (CCD) and side-to-side difference in the CCD were measured for radiographic analysis.

Results

A total of 43 patients (22 acute, 21 chronic) were included in the study. The mean patient age was 43.4 ± 11.4 years, with a mean follow-up of 3.4 years (range, 2.0-7.5 years). With regard to the ASES score, 92% of patients achieved the MCID, 81% achieved the SCB, and 49% reached or exceeded the PASS. There was no significant difference when stratifying by type (III vs V) or chronicity (acute vs chronic) of injury (both P > .05). The Rowe score improved from 66.6 ± 15.9 preoperatively to 88.6 ± 12.3 postoperatively, the CM score from 61.6 ± 18.8 to 87.4 ± 15.1, and the SST score from 6.2 ± 3.6 to 9.4 ± 3.7 (all P < .001). The postoperative side-to-side difference in the CCD was 3.1 ± 2.7 mm, with type III injuries (2.4 ± 1.9 mm) showing significantly lower measurements compared with type V (4.2 ± 3.4 mm) (P = .02). No significant trend was found between joint reduction and the improvement in clinical outcomes (P > .05).

Conclusion

Patients undergoing ACCR for acute and chronic type III and V AC joint injuries maintained significant improvement in clinical and radiographic outcomes at a minimum 2-year follow-up. Additionally, 81% of patients reached the SCB after surgical reconstruction.

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.

Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults

BACKGROUND

Dislocation of the acromioclavicular joint is one of the most common shoulder injuries in a sport-active population. The question of whether surgery should be used remains controversial. This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To assess the effects (benefits and harms) of surgical versus conservative (non-surgical) interventions for treating acromioclavicular dislocations in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to June 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 6), MEDLINE (1946 to June 2019), Embase (1980 to June 2019), and LILACS (1982 to June 2019), trial registries, and reference lists of articles. There were no restrictions based on language or publication status.

SELECTION CRITERIA

We included all randomised and quasi-randomised trials that compared surgical with conservative treatment of acromioclavicular dislocation in adults.

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study screening and selection, 'Risk of bias' assessment, and data extraction. We pooled data where appropriate and used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included five randomised trials and one quasi-randomised trial. The included trials involved 357 mainly young adults, the majority of whom were male, with acute acromioclavicular dislocation. The strength of the findings in all studies was limited due to design features, invariably lack of blinding, that carry a high risk of bias. Fixation of the acromioclavicular joint using hook plates, tunnelled suspension devices, coracoclavicular screws, acromioclavicular pins, or (usually threaded) wires was compared with supporting the arm in a sling or similar device. After surgery, the arm was also supported in a sling or similar device in all trials. Where described in the trials, both groups had exercise-based rehabilitation. We downgraded the evidence for all outcomes at least two levels, invariably for serious risk of bias and serious imprecision.Low-quality evidence from two studies showed no evidence of a difference between groups in shoulder function at one year, assessed using the Disability of the Arm, Shoulder, and Hand questionnaire (DASH) (0 (best function) to 100 (worst function)): mean difference (MD) 0.73 points, 95% confidence interval (CI) -2.70 to 4.16; 112 participants. These results were consistent with other measures of function at one-year or longer follow-up, including non-validated outcome scores reported by three studies. There is low-quality evidence that function at six weeks may be better after conservative treatment, indicating an earlier recovery. Very low-quality evidence from one trial found no difference between groups in participants reporting pain at one year: risk ratio (RR) 1.32, 95% CI 0.54 to 3.19; 79 participants. There is very low-quality evidence that surgery may not reduce the risk of treatment failure, usually resulting in non-routine secondary surgery: 14/168 versus 15/174; RR 0.99, 95% CI 0.51 to 1.94; 342 participants, 6 studies. The main source of treatment failure was complications related to surgical implants in the surgery group and persistent symptoms, mainly discomfort, due to the acromioclavicular dislocation in the conservatively treated group.There is low-quality evidence from two studies that there may be little or no difference between groups in the return to former activities (sports or work) at one year: 57/67 versus 62/70; RR 0.96, 95% CI 0.85 to 1.10; 137 participants, 2 studies. Low-quality but consistent evidence from four studies indicated an earlier recovery in conservatively treated participants compared with those treated with surgery. There is low-quality evidence of no clinically important difference between groups at one year in quality of life scores, measured using the 36-item or 12-item Short Form Health Survey (SF-36 or SF-12) (0-to-100 scale, where 100 is best score), in either the physical component (MD -0.63, 95% CI -2.63 to 1.37; 122 participants, 2 studies) or mental component (MD 0.47 points, 95% CI -1.51 to 2.44; 122 participants). There is very low-quality and clinically heterogenous evidence of a greater risk of an adverse event after surgery: 45/168 versus 16/174; RR 2.82, 95% CI 1.65 to 4.82; 342 participants, 6 studies; I² = 48%. Common adverse outcomes were hardware complications or discomfort (18.5%) and infection (8.7%) in the surgery group and persistent symptoms (7.1%), mainly discomfort, in the conservatively treated group. The majority of surgical complications occurred in older studies testing now-outdated devices known for their high risk of complications. The very low-quality evidence from one study (70 participants) means that we are uncertain whether there is a between-group difference in patient dissatisfaction with cosmetic results.It is notable that the evidence for function, return to former activities, and quality of life came from the two most recently conducted studies, which tested currently used devices and interventions in clearly defined participant populations that represented the commonly perceived population for which there is uncertainty over the use of surgery. There were insufficient data to conduct subgroup analysis relating to type of injury and whether surgery involved ligament reconstruction or not.

AUTHORS' CONCLUSIONS

There is low-quality evidence that surgical treatment has no additional benefits in terms of function, return to former activities, and quality of life at one year compared with conservative treatment. There is, however, low-quality evidence that people treated conservatively had improved function at six weeks compared with surgical management. There is very low-quality evidence of little difference between the two treatments in pain at one year, treatment failure usually resulting in secondary surgery, or patient satisfaction with cosmetic result. Although surgery may result in more people sustaining adverse events, this varied between the trials, being more common in techniques such as K-wire fixation that are rarely used today. There remains a need to consider the balance of risks between the individual outcomes: for example, surgical adverse events, including wound infection or dehiscence and hardware complication, against risk of adverse events that may be more commonly associated with conservative treatment such as persistent symptoms or discomfort, or both.There is a need for sufficiently powered, good-quality, well-reported randomised trials of currently used surgical interventions versus conservative treatment for well-defined injuries.

Surgical management of chronic high-grade acromioclavicular joint dislocations: a systematic review

BACKGROUND

To date, no gold-standard technique exists for the treatment of chronic acromioclavicular joint (ACJ) instability. We systematically reviewed the clinical results of 3 main categories of ACJ reconstruction for high-grade chronic instability.

METHODS

A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The inclusion criteria were clinical studies involving patients with ACJ instability (Rockwood grades III-VI) for at least 6 weeks, managed with ACJ stabilization, with a minimum 1-year follow-up. Depending on the surgical technique, patients were divided into 1 of 3 groups: nonbiological fixation between the coracoid and clavicle, for example, suture loops and synthetic ligaments (group 1); biological reconstruction of the coracoclavicular ligaments, for example, allograft or autograft ligament reconstruction (group 2); and ligament and/or tendon transfer, for example, the Weaver-Dunn procedure (group 3). Patient demographic characteristics, functional scores, radiographic outcomes, and complications were compared.

RESULTS

Two independent investigators reviewed 960 articles. A total of 27 studies met the inclusion criteria, comprising 590 patients divided into 1 of 3 groups. The complication rates were similar among the 3 groups: 15% for nonbiological fixation, 15% for biological reconstruction, and 17% for ligament and/or tendon transfer, with failure rates of 8%, 7%, and 5%, respectively. In terms of functional results, the mean Constant score was 87.2 points for nonbiological fixation (n = 89), 92.4 points for biological reconstruction (n = 86), and 87.4 points for ligament and/or tendon transfer (n = 49).

CONCLUSION

On comparison of the results of 3 different ACJ reconstruction methods, all techniques showed similar complication rates. Among the level II studies, ACJ reconstruction with a tendon graft showed superior results.

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.