Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations

Dynamic instability of the acromioclavicular joint: A new classification for acute AC joint separation

Background

Acute acromioclavicular (AC) dislocation is classified according to Rockwood (RW). Although of clinical relevance, dynamic horizontal translation (DHT) is not listed in this classification or in frequently used clinical evaluation tools. The aim of this study was (a) to evaluate vertical and horizontal AC joint instabilities and assess their combined occurrence and clinical appearance in a consecutive group of patients, as well as (b) to develop a new classification of acute AC joint dislocation.

Method

A consecutive group of 61 patients (seven female, 54 male) with a mean age of 34.5 years (18.9–60.1) were included in the study. All patients underwent posttraumatic clinical—Taft Score (TF), Acromioclavicular Joint Instability Score (ACJI), Constant Score (CS), Subjective Shoulder Value (SSV)—and radiological (bilateral anteroposterior stress and bilateral Alexander views) evaluation.

Results

According to the RW classification, the following AC dislocations were present: eight (13.1%) type I, nine (14.8%) type II, 22 (36.1%) type III, and 22 (36.1%) type V. Based on the clinical and radiographic results, a new classification is proposed: Type I instabilities show only a partial vertical displacement (≤30% coracoclavicular distance [CCD]) and type II a complete vertical displacement (>30% CCD). Both type I and II are further graded into none or partial (A) and complete DHT (B) as seen on bilateral Alexander views.

Conclusion

DHT can be found in low-grade instabilities and lead to inferior clinical results in the posttraumatic situation.

Functional and Radiographic Outcomes After Allograft Anatomic Coracoclavicular Ligament Reconstruction

OBJECTIVES

To analyze the functional and radiographic outcomes of anatomic coracoclavicular ligament reconstruction (ACCR) using allograft tendon without interference screw fixation.

DESIGN

Retrospective nonrandomized study.

SETTING

Level I trauma center (University Hospital).

PATIENTS

Seventeen patients (mean age of 44 years) with Rockwood III through V acromioclavicular joint disruptions. Twelve of 17 patients had a primary reconstruction, including 4 patients sustaining their injuries as part of a polytrauma incident. Five of 17 patients were revisions of a previously failed acromioclavicular reconstruction procedure.

INTERVENTION

Open ACCR using hamstring allograft with high-strength suture augmentation and knotted graft fixation without interference screws.

MAIN OUTCOME MEASURES

Clinical and patient reported outcome measures including Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and visual analog scale scores for pain and radiographic outcomes.

RESULTS

The average final postoperative Simple Shoulder Test and American Shoulder and Elbow Surgeons scores were 10.8 and 80.5, respectively. The average final postoperative visual analog scale pain was 1.8. All patients demonstrated clavicle tunnel widening on final postoperative radiographs compared with immediate postoperative radiographs. The overall complication rate was 36%, with no clavicle or coracoid fractures.

CONCLUSIONS

Open ACCR using hamstring allograft tendon secured with a square knot and high-strength suture augmentation yields equivalent outcomes to those repairs requiring an additional interference screw. Clavicle tunnel widening predictably occurs, but the clinical significance is undetermined. It appears therefore that an interference screw is not needed. Larger comparison studies are needed.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Current practice in the management of Rockwood type III acromioclavicular joint dislocations-National survey

PURPOSE

Our aim was to conduct this survey among consultant shoulder surgeons in the United Kingdom to document the current management of Rockwood type III acromioclavicular joint (ACJ) injuries.

METHODS

British Elbow and Shoulder Society Research Committee-approved online survey was used and 137 responses were collected within 3 months.

RESULTS

One hundred percent of responders would treat type III injuries conservatively initially. Routine physiotherapy would be offered by 86% of surgeons. The patient's factors that influence the decision to consider surgery are pre-injury functional demand, current functional deficit, pain and patient request for surgery. Across all groups the mean time to surgical intervention from injury was 3.8 months. About 45% of all consultants would use the same technique for all cases and there were differences between the varieties of techniques used by surgeons, depending on their degree of experience. LockDown was the most widely used technique in all groups of patients. This was followed by Ligament Augmentation & Reconstruction System (LARS), hook plate and Arthroscopic TightRope/DogBone technique for acute injuries. LARS, modified Weaver-Dunn and ACJ resection were used most commonly after LockDown for delayed cases.

CONCLUSION

Our survey revealed the current trends in clinical practice to treat symptomatic Rockwood type III ACJ injuries, but it also confirmed the controversial and complex management differences, which vary among shoulder surgeons in the United Kingdom.

Treatment of Rockwood Type III Acromioclavicular Joint Dislocation

While non-operative treatment with structured rehabilitation tends to be the strategy of choice in the management of Rockwood type III acromioclavicular joint injury, some advocate surgical treatment to prevent persistent pain, disability, and prominence of the distal clavicle. There is no clear consensus regarding when the surgical treatment should be indicated, and successful clinical outcomes have been reported for non-operative treatment in more than 80% of type III acromioclavicular joint injuries. Furthermore, there is no gold standard procedure for operative treatment of type III acromioclavicular joint injury, and more than 60 different procedures have been used for this purpose in clinical practice. Among these surgical techniques, recently introduced arthroscopic-assisted procedures involving a coracoclavicular suspension device are minimally invasive and have been shown to achieve successful coracoclavicular reconstruction in 80% of patients with failed conservative treatment. Taken together, currently available data indicate that successful treatment can be expected with initial conservative treatment in more than 96% of type III acromioclavicular injuries, whereas minimally invasive surgical treatments can be considered for unstable type IIIB injuries, especially in young and active patients. Further studies are needed to clarify the optimal treatment approach in patients with higher functional needs, especially in high-level athletes.

Arthroscopically assisted reduction of acute acromioclavicular joint dislocation using a single double-button device: Medium-term clinical and radiological outcomes

INTRODUCTION

Double-button devices for endoscopic management of acute acromioclavicular joint dislocation (ACJD) provide satisfactory short-term functional and radiological results. However, little exists in the literature regarding the long- and medium-term results of these implants, especially regarding the evolution of the acromioclavicular joint (ACJ).

HYPOTHESIS

Satisfactory and steady long- and medium-term outcomes can be achieved in patients with acute ACJD undergoing endoscopically assisted ACJ repair using a single double-button device.

MATERIAL AND METHOD

A retrospective single-center study was conducted in patients with acute Rockwood III and IV ACJD treated endoscopically with a single double-button device from October 2008 to October 2010, allowing a minimum 5-year follow-up. Functional evaluation used Constant and Quick-DASH scores. Clinical evidence of dislocation recurrence was combined with bilateral Zanca views to assess coracoclavicular distance. Acromioclavicular osteoarthritis was evaluated on the Paxinos test and Zanca views.

RESULTS

Nineteen of the 25 operated patients were seen at a mean 76.9±8.5 months' follow-up. Mean age was 34.4±8.3 years. Mean Constant and Quick-DASH scores were 96.2±5.1 and 0.9±1.6 points, respectively. Four patients had a recurrence of their initial dislocation, 3 of whom had positive Paxinos test, whereas the 15 patients without recurrence had a negative test (p=0.004). Five patients had radiological evidence of ACJ osteoarthritis: all 4 patients with recurrence and 1 without (p=0.001).

CONCLUSION

Long- and medium-term radioclinical outcome of endoscopically assisted management of acute ACJD using a single double-button device seems to be satisfactory and steady over time. Recurrence of the initial dislocation appears to be related to onset of degenerative ACJ arthropathy.

LEVEL OF EVIDENCE

Therapeutic type IV-Retrospective case series.

[Current aspects and new techniques in dislocation of the shoulder joint]

With 12% of all injuries concerning the shoulder, acromioclavicular (AC) joint dislocations are a common injury especially in young and active patients. The Rockwood classification is widely accepted, which differentiates between six types depending on the degree of injury and the vertical dislocation. Because the classification does not adequately address the horizontal instability, its benefits are questionable and there is currently no consensus. For this reason, the classification and the therapy of these injuries are increasingly becoming the subject of scientific investigations. Whereas conservative treatment for type I and II injuries and operative treatment for type IV-VI injuries are widely accepted, there is still no agreement in treating type III lesions. The goal of this review article is to present the current evidence for the diagnostics, different classifications and therapeutic possibilities.

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

PURPOSE AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

New quantitative radiographic parameters for vertical and horizontal instability in acromioclavicular joint dislocations

PURPOSE

The aim of this study was to identify the most accurate and reliable quantitative radiographic parameters for assessing vertical and horizontal instability in different Rockwood grades of acromioclavicular joint (ACJ) separations. Furthermore, the effect of projectional variation on these parameters was investigated in obtaining lateral Alexander view radiographs.

METHODS

A Sawbone model of a scapula with clavicle was mounted on a holding device, and acromioclavicular dislocations as per the Rockwood classification system were simulated with the addition of horizontal posterior displacement. Projectional variations for each injury type were performed by tilting/rotating the Sawbone construct in the coronal, sagittal or axial plane. Radiographic imaging in the form of an anterior-posterior Zanca view and a lateral Alexander view were taken for each injury type and each projectional variation. Five newly defined radiographic parameters for assessing horizontal and vertical displacement as well as commonly used coracoclavicular distance view were measured. Reliability, validity and the effect of projectional variation were investigated for these radiographic measurements.

RESULTS

All radiographic parameters showed excellent intra- and interobserver reliability. The validity was excellent for the acromial centre line to dorsal clavicle (AC-DC) in vertical displacement and for the glenoid centre line to posterior clavicle (GC-PC) in horizontal displacement, whilst the remaining measurements showed moderate validity. For AC-DC and GC-PC, convergent validity expressed strong correlation to the effective distance and discriminant validity demonstrated its ability to differentiate between various grades of ACJ dislocations. The effect of projectional variation increased with the degree of deviation and was maximal (3 mm) for AC-DC in 20° anteverted malpositioning and for GC-PC in 20° retroverted malpositioning.

CONCLUSIONS

AC-DC and the GC-PC are two novel quantitative radiographic parameters of vertical and horizontal instability in ACJ dislocations that demonstrate excellent reliability and validity with reasonable inertness to malpositioning. The use of AC-DC for assessing vertical displacement and GC-PC for assessing horizontal displacement in a single Alexander view is recommended to guide the appropriate management of ACJ dislocations. A better appreciation of the degree of horizontal instability, especially in lower Rockwood grades (II, III) of ACJ dislocations, may improve management of these controversial injuries.

New insights in the treatment of acromioclavicular separation

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

Clinical factors that affect perceived quality of life in arthroscopic reconstruction for acromioclavicular joint dislocation

OBJECTIVE

To analyse the results of arthroscopic repair of acromioclavicular dislocation in terms of health-related quality of life.

MATERIAL AND METHOD

Prospective study of patients with acromioclavicular dislocation Rockwood grade iii-v, treated arthroscopically with a mean follow up of 25.4 months. The demographics of the series were recorded and evaluations were performed preoperatively, at 3 months and 2 years with validated questionnaires as Short Form-36 Health Survey (SF-36), visual analogue scale (VAS), The Disabilities of the Arm, Shoulder and Hand (DASH), Constant-Murley Shoulder Outcome Score (Constant) and Walch-Duplay Score (WD).

RESULTS

Twenty patients, 17 men and 3 women with a mean age of 36.1 years, were analysed. According to the classification of Rockwood, 3 patients were grade iii, 3 grade iv and 14 grade v. Functional and clinical improvement was detected in all clinical tests (SF-36, VAS and DASH) at 3 months and 2 years follow up (P<.001). The final Constant score was 95.3±2.4 and the WD was 1.8±0.62. It was not found that the health-related quality of life was affected by any variable studied except the evolution of DASH.

CONCLUSIONS

The health-related quality of life (assessed by SF-36) in patients undergoing arthroscopic repair of acromioclavicular joint dislocation grades iii-v was not influenced by gender, age, grade, displacement, handedness, evolution of the VAS, scoring of the Constant or by the WD. However, it is correlated with the evolution in the DASH score.

Palmaris longus tendon graft versus modified Weaver-Dunn procedure via dynamic button system for acromioclavicular joint reconstruction in chronic cases

BACKGROUND

The hypothesis of this clinical study was that coracoclavicular (CC) reconstruction using autogenic palmaris longus graft through the GraftRope (PLG) system (Arthrex, Inc., Naples, FL, USA) would provide superior clinical and radiologic results compared with modified Weaver-Dunn procedure with the dynamic TightRope (Arthrex, Inc.) system (WDT).

METHODS

Between 2008 and 2013, 32 patients (average age, 39.7 years; range, 22-60 years) underwent surgical reconstruction of chronic acromioclavicular (AC) joint dislocation. A modified WDT procedure was performed in 16 patients and autogenous PLG was performed in the other 16 patients. Patient data were collected retrospectively, with a final follow-up of 44.9 months (range, 29-60 months). The degree of AC joint displacement was evaluated by measuring the CC distance on the anteroposterior and axillary view. Clinical and functional outcomes were compared by American Shoulder and Elbow Surgeons and the Constant scores at final follow-up.

RESULTS

Comparison between the WDT and PLG groups showed a significantly better outcome in the American Shoulder and Elbow Surgeons and the Constant scores (P < .01), in favor of the PLG group. Both groups showed an increased CC distance compared with the uninjured side, with a mean difference of 1.1 mm for the PLG and 3.3 mm for the WDT groups. A tolerable loss of reduction within the follow-up time was observed. Reduction loss was higher with the WDT group (P < .05).

CONCLUSION

CC palmaris longus tendon graft reconstruction with GraftRope system was associated with functional and radiologic benefits. The palmaris longus graft with GraftRope system could be used in chronic cases.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV: Therapeutic study-cases series.

Anatomic Coracoclavicular Ligament Reconstruction for the Treatment of Acute Acromioclavicular Joint Dislocation: Minimum 10-Year Follow-up

Background:

The long-term clinical and radiographic outcomes following coracoclavicular (CC) ligament reconstruction for the operative treatment of acute acromioclavicular (AC) joint dislocation remain uncertain. The purpose of the present study was to determine the long-term clinical and radiographic outcomes of CC ligament reconstruction and to identify risk factors for unfavorable outcomes.

Methods:

We reviewed 20 cases of AC joint dislocation in 19 patients (18 male and 1 female; mean age, 32.3 years) that were treated with single-bundle reconstruction. The mean duration of follow-up was 12.7 years. We measured the CC vertical distance (CCD) on the anteroposterior view and compared the affected and unaffected sides (CCD ratio). We divided the patients into those with a CCD ratio of <25% (Group 1) and those with a CCD ratio of ≥25% (Group 2). We radiographically investigated the clavicular tunnel anteroposterior (CTAP) angle, clavicular tunnel ratio, and coracoid tunnel orientation on the basis of the entry and exit points at the base of the coracoid. For the coracoid tunnel orientation, we compared center-center orientation and noncenter-center orientation.

Results:

Group 1 comprised 17 cases (85%), and Group 2 comprised 3 cases (15%). At the time of the latest follow-up, Group 1 had a significantly higher mean Constant score than Group 2 (98.2 compared with 90.7; p = 0.038). Of the 3 radiographic parameters, only the CTAP angle was significantly different between the 2 groups (p < 0.0001). Two (67%) of the 3 cases in Group 2 were associated with posterior AC joint displacement.

Conclusions:

CC ligament reconstruction for the treatment of acute AC joint dislocation resulted in successful long-term clinical and radiographic outcomes. It is important to decrease the CTAP angle and to ensure proper anatomic placement of the clavicular and coracoid tunnels at the time of surgery.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acromioclavicular joint dislocation treated with Bosworth screw and additional K-wiring: results after 7.8 years - still an adequate procedure?

BACKGROUND

The acromioclavicular (AC) joint dislocation is a major reason for shoulder instability. Different concepts of treatment and surgical methods are described in the literature. Thus, the purpose of this study was to present our data of long-term follow-up of patients having undergone treatment of acromioclavicular (AC) joint dislocation using the Bosworth Screw with additional K-wiring.

METHODS

This study was conducted as a retrospective single centre data analysis. All patients treated operatively for AC joint dislocation with a Bosworth screw and additional K-wire fixation at our Department were asked to participate in this study.

RESULTS

The study population consisted of 22 patients, 20 male and 2 female, with a mean age of 40 years ±15.6 years. Three grade-II lesions, 13 grade-III lesions, four grade-IV lesions and two grade-V lesions according to the Rockwood classification were found. The overall mean clinical outcome at the latest follow up was: Constant 95, DASH 6.4, ASES 94.6, SST 99.02, UCLA 33.1, ACJI 91.82 and VAS 0.29 - representing a good-to-excellent long-term outcome in all patients after at least 2 years follow-up (range; 2 - 19 years). Overall, 19 patients (86%) reported to be very satisfied with the achieved result, 15 patients (68%) reported to be able to participate in every sports activity and 16 patients (73%) reported to be able to perform their daily work without limitations. Overall, complications occurred in three patients (14%). Only one patient remained unsatisfied with the achieved result.

CONCLUSION

Summarizing, our reported results showed that surgical fixation of acute AC joint dislocation with a Bosworth screw and additional K-wire fixation leads to good-to-excellent functional outcome and highly satisfactory results in the majority of patients. Despite its complications, in accordance with our results, Bosworth screw fixation with additional K-wiring in AC joint dislocation represents an adequate surgical procedure.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction for Acute Acromioclavicular Dislocation Using 2 Clavicular and 1 Coracoid Cortical Fixation Buttons With Suture Tapes

PURPOSE

To introduce an arthroscopically assisted coracoclavicular (CC) fixation technique using a cortical fixation button device and to evaluate the clinical and radiologic outcomes in patients with acute acromioclavicular (AC) dislocation who were treated with the technique.

METHODS

Twenty-one consecutive patients with grade III and V acute AC dislocation who underwent arthroscopically assisted CC ligament reconstruction using a cortical fixation button device were prospectively enrolled. Our fixation technique involved using a cortical fixation button device consisting of 1 coracoid button and 2 clavicular buttons connected with 2 suture tapes to reconstruct the conoid and trapezoid ligaments, respectively. Clinical outcomes were evaluated and CC distance and horizontal displacement of the AC joint were measured.

RESULTS

The mean follow-up period was 27.2 months (range, 24-32 months). The average CC distance of the injured shoulder was 17.2 ± 5.2 mm preoperatively, which represented an increase of 103% ± 42% compared with the uninjured shoulder. The CC distance was significantly reduced to 8.5 ± 1.5 mm after surgery (P < .001). At the final follow-up, the CC distance was maintained in 20 patients (95%) without loss of reduction. No significant radiologic difference was found in horizontal displacement of the AC joint immediately after the operation and at the final follow-up (P = .422). The average American Shoulder and Elbow Surgeons and Constant scores were 95.7 ± 3.6 and 95.4 ± 3.4, respectively. There were 3 complications, including 1 reduction loss, 1 coracoid process fracture, and 1 CC interval ossification.

CONCLUSIONS

Satisfactory clinical and radiologic outcomes were obtained simultaneously by arthroscopically assisted CC reconstruction using cortical fixation buttons. This reconstruction technique provided sufficient stability of the AC joint by using 2 clavicular holes to reconstruct the conoid and trapezoid ligaments separately. Therefore, arthroscopically assisted CC ligament reconstruction using a cortical fixation button device for management of acute AC dislocation is considered a viable treatment option for restoring stability to the AC joint.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The anterior borders of the clavicle and the acromion are not always aligned in the intact acromioclavicular joint: a cadaveric study

BACKGROUND

The aim of this study was to find reliable anatomic landmarks of the normal acromioclavicular joint (ACJ) that could enable the precise evaluation of the horizontal displacement of the clavicle after dislocation. The hypothesis was that the anterior borders of the acromion and the clavicle are always aligned in intact ACJs.

MATERIALS AND METHODS

In 30 cadaveric specimens, the anterior and posterior borders of the ACJ's articular facets and the most prominent anterior and posterior bony landmarks of the acromion and the clavicle were identified. The anterior and posterior overhang of the acromion and the clavicle was measured in relation to the borders of the articular facets. Therefore, the possible anterior and posterior alignment of the ACJ was evaluated.

RESULTS

Anteriorly, only 18 ACJs (60%) were aligned whereas 7 (24%) had major overhang of the acromion and 3 (10%) had major overhang of the clavicle. Similarly, 18 cases (60%) were posteriorly aligned, whereas 6 (20%) had major clavicular overhang and 4 (14%) had major overhang of the acromion. In 78% of these cases, the ACJ was aligned as well anteriorly as posteriorly (P < .001). Finally, the larger the width of the acromion (P = .032) or the clavicle (P = .049), the better the posterior joint alignment.

CONCLUSION

Our hypothesis was not verified. The acromion and clavicle are not perfectly aligned in a significant number of specimens with intact ACJs (40% of cases). The most reliable landmarks remain their articular facets.

Early complications of acromioclavicular joint reconstruction requiring reoperation

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Quantification of dynamic posterior translation in modified bilateral Alexander views and correlation with clinical and radiological parameters in patients with acute acromioclavicular joint instability

INTRODUCTION

Classification of AC-joint instability is based on radiologic evaluation of anteroposterior (a.p.) stress views of both shoulders, neglecting the horizontal component of instability. Recent studies have proposed an association of dynamic posterior translation (DPT) and inferior clinical results. The purpose of this study was to quantify DPT in modified Alexander views and correlate it with other radiological and clinical data.

MATERIALS AND METHODS

Thirty-two patients (4 f, 28 m, mean age 34.1) with acute AC-joint dislocation (16 = RW III, 16 = RW V) underwent radiological examination including bilateral a.p. stress views with measurement of the coracoclavicular distance (CCD) and bilateral modified Alexander views with different approaches to quantify DPT (overlapping area OA_AC, overlapping length OL_AC). In addition, the Constant Score, Subjective Shoulder Value, Taft Score (TF), and the Acromioclavicular Joint Instability Score (ACJI) were obtained.

RESULTS

In Rockwood (RW) type III injuries, a mean CCD of 15.8 (9.8-22.8) mm, OA_AC of 50.9 (0-216.6) mm², and OL_AC of 6.5 (-4.7-17.9) mm were found. RW V patients showed a CCD of 23.1 (13.7-32.0) mm; OA_AC 7.0 (0-92.3) mm²; and OL_AC -4.8 (-19.6-9.8) mm. Particularly in RW III the CCD, OA_AC and OL_AC revealed significant correlation with the ACJI (r = -0.64/r = 0.72/r = 0.68, p < 0.05) and TF (r = -0.56/r = 0.68/r = 0.51, p < 0.05). The proposed quantification tools for DPT were found to have a moderate-to-strong correlation with the score results, especially with AC-joint specific scores. RW type V injuries had a moderate correlation with clinical parameters (OA_AC with ACJI: r = 0.44, p > 0.05 and OL_AC with TF: r = -0.45, p > 0.05).

CONCLUSIONS

Measuring the OL_AC is a convenient way for quantifying DPT in modified Alexander views. It showed significant correlation with clinical scores, indicating the relevance of DPT in patients with AC-joint injury.

Treatment of Symptomatic Acromioclavicular Joint Instability by a Docking Technique: Clinical Indications, Surgical Technique, and Outcomes

PURPOSE

To report functional and objective outcomes resulting from surgical treatment of patients with symptomatic type III through V acromioclavicular (AC) joint injury by use of a modification of the anatomic AC joint reconstruction developed by Carofino and Mazzocca.

METHODS

The study included all patients treated in 2009-2014 who presented with a history of direct trauma to the shoulder; deformity of the AC joint on clinical examination; radiographic findings that would classify the injury as a Rockwood type III, IV, or V injury; AC joint instability on clinical examination; and self-reported deficits of arm function on initial presentation, in whom a comprehensive and directed nonoperative program failed. The surgical procedure used an allograft with reinforcing internal sutures passed around the coracoid and through anatomically positioned clavicular holes for the coracoclavicular (CC) ligaments, used a docking technique for reconstruction of the superior AC ligaments, and included repair of the native AC ligaments. Outcomes were reported for patients with a minimum follow-up period of 1.5 years. Outcome measurements included dynamic-static stability evaluation and Disabilities of the Arm, Shoulder and Hand (DASH) scores.

RESULTS

The study included 15 patients with 15 affected shoulders. The postsurgical follow-up period averaged 3 years (range, 1.5-5 years). Postoperatively, one patient showed loss of reduction after a fall. All others showed 2-dimensional radiographic stability and 3-dimensional dynamic clinical stability. Static radiographic measurement of the CC distance at discharge averaged 0.93 cm compared with 2.7 cm on initial examination (P < .0001). Patient-reported outcomes at an average of 3 years' follow-up showed a DASH score of 13 compared with a preoperative DASH score of 51 (P < .0001).

CONCLUSIONS

This study confirms that anatomic CC ligament reconstruction and repair or reconstruction of the AC ligaments help restore arm function as shown by the patient-specific and clinical outcome metrics. These results were achieved by correction of the deformity, which in turn allowed for the obtainment of static and dynamic stability.

LEVEL OF EVIDENCE

Level IV.

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

BACKGROUND AND HYPOTHESIS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV.

Arthroscopic Reconstruction After Acute Acromioclavicular Separation Injuries

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

Management of chronic unstable acromioclavicular joint injuries

Abstract

The acromioclavicular joint represents the link between the clavicle and the scapula, which is responsible for the synchronized dynamic of the shoulder girdle. Chronic acromioclavicular joint instability involves changes in the orientation of the scapula, which provokes cinematic alterations that might result in chronic pain. Several surgical strategies for the management of patients with chronic and symptomatic acromioclavicular joint instability have been described. The range of possibilities includes anatomical and non-anatomical techniques, open and arthroscopy-assisted procedures, and biological and synthetic grafts. Surgical management of chronic acromioclavicular joint instability should involve the reconstruction of the torn ligaments because it is accepted that from three weeks after the injury, these structures may lack healing potential. Here, we provide a review of the literature regarding the management of chronic acromioclavicular joint instability.

Level of evidence

Expert opinion, Level V.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Minimally Invasive Double-Button Fixation of Displaced Lateral Clavicular Fractures in Athletes

BACKGROUND

Early union and a rapid return to prior function are the priorities for young athletes with lateral clavicular fractures. Furthermore, it is essential to avoid nonunion in this subgroup of patients, as this is frequently associated with persistent pain, restriction of movement, and loss of strength and endurance of the shoulder.

PURPOSE

To analyze the time to return to sport, functional outcomes, and complications in a group of athletes with displaced lateral clavicular fractures treated using closed reduction and minimally invasive double-button fixation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 21 athletes with displaced lateral clavicular fractures were treated with closed reduction and minimally invasive double-button fixation between March 2008 and October 2013. Patients completed a questionnaire focused on the time to return to sport and treatment course. Functional outcomes were assessed with the Constant score and the short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Pain was evaluated with the visual analog scale (VAS). Radiographs were reviewed to identify radiographic union, malunion, and nonunion.

RESULTS

Of the 21 study patients, 20 returned to sport after treatment; 100% returned to the same level. The mean time to return to play was 78 days (range, 41-120 days). Four patients (20%) returned to sport less than 6 weeks after surgery, 14 (70%) returned between 6 and 12 weeks after surgery, and 2 (10%) returned after 12 weeks. The mean Constant score was 89.1 ± 4.2 (range, 79-100), the mean QuickDASH score was 0.4 ± 2.6 (range, 0-7.1), and the mean VAS pain score was 0.4 ± 1.0 (range, 0-3) at final follow-up (mean, 41 months). The only complication was asymptomatic nonunion. Hardware removal was not necessary in any patient.

CONCLUSION

Closed reduction and minimally invasive double-button fixation of displaced lateral clavicular fractures in athletes was successful in terms of returning to the previous level of athletic activity regardless of the type of sport, with excellent clinical results and a low rate of complications.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, prognostic case series.

BiPOD Arthroscopic Acromioclavicular Repair Restores Bidirectional Stability

Stabilizing the acromioclavicular joint in the vertical and horizontal planes is challenging, and most current techniques do not reliably achieve this goal. The BiPOD repair is an arthroscopically assisted procedure performed with image intensifier guidance that reconstructs the coracoclavicular ligaments as well as the acromioclavicular ligaments to achieve bidirectional stability. Repair is achieved with a combination of 2-mm FiberTape (Arthrex, Naples, Florida) and 20-mm Poly-Tape (Neoligaments, Leeds, England) to achieve rigid repair, prevent bone abrasion, and promote tissue ingrowth. This study is a prospective review of the first 6 patients treated for high-grade acute acromioclavicular injury with the BiPOD technique. The study included 6 men who were 21 to 36 years old (mean, 27 years). At 6-month follow-up, complications were recorded and radiographic analysis was used to determine the coracoclavicular distance for vertical reduction and the amount of acromioclavicular translation on the Alexander axillary view was used to determine horizontal reduction. One patient had a superficial infection over the tape knot. The difference in coracoclavicular distance between the operated side and the uninvolved side was 9±2 mm preoperatively and 0.3±2 mm at 6-month follow-up. On Alexander axillary view, all 6 patients showed stable reduction, which is defined as a clavicle that is in line with the acromion. The findings show that BiPOD acromioclavicular reconstruction restores bidirectional stability of the acromioclavicular joint at 6 months. [Orthopedics. 2017; 40(1):e35-e43.].

Posterior Distal Clavicle Beveling for Chronic Nonincarcerated Type IV Acromioclavicular Separations: Surgical Technique and Early Clinical Outcomes

PURPOSE

To describe the arthroscopic partial posterior distal clavicle beveling technique for treatment of chronic nonincarcerated type IV acromioclavicular (AC) separations and report clinical outcomes and return to sport.

METHODS

All patients who underwent the arthroscopic partial distal clavicle beveling technique and met eligibility criteria were identified and retrospectively reviewed. Inclusion criteria included the clinical diagnosis of a chronic nonincarcerated type IV AC separation and a minimum follow-up period of 24 months. Subjects completed the American Shoulder Elbow Surgeons shoulder assessment and a study-designed questionnaire. Radiographic images and clinical charts were also reviewed.

RESULTS

This study identified 15 consecutive patients with 2 lost to follow-up, resulting in inclusion of 13 subjects (9 males and 4 females). Dominant arm was involved in 77% of cases. Mean age at operation was 33.2 years (range, 19-56 years). The mean period between injury and operation was 12.5 months (range, 3-37 months), and follow-up was 48.5 months (range, 24-126 months). The mean preoperative ASES score was 46.6 ± 16.9 (range, 33-68), and the mean postoperative ASES score was 87.3 ± 17.4 (range, 50-100) (P < .0001). All 9 athletes in the study returned to competition with a mean recovery period of 2.3 months (range, 2 weeks to 4 months). Mean timeframe for return to work was 2 weeks (range, 1 day to 2 months). One subject underwent a subsequent coracoclavicular ligament reconstruction for continued pain. The mean satisfaction level was 4.3 out of 5, and 91% would choose to have the surgery again. One subject indicated dissatisfaction with shoulder appearance.

CONCLUSIONS

The arthroscopic partial distal clavicle beveling procedure for nonincarcerated type IV AC separations resulted in a significant reduction in pain, improved daily function, and early return to sport.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Axial-Plane Biomechanical Evaluation of 2 Suspensory Cortical Button Fixation Constructs for Acromioclavicular Joint Reconstruction

BACKGROUND

Although numerous suture-button fixation techniques for acromioclavicular (AC) joint reconstruction have been validated with biomechanical testing in the superior direction, clinical reports continue to demonstrate high rates of construct slippage and breakage.

PURPOSE

To compare the stability of a novel closed-loop double Endobutton construct with a commercially available cortical button system in both the axial and superior directions.

STUDY DESIGN

Controlled laboratory study.

METHODS

Six matched pairs of fresh-frozen cadaveric upper extremities were anatomically dissected and prepared to simulate a complete AC joint dislocation. One side of each pair was reconstructed with the double Endobutton (DE) construct and other side with the dog bone button (DB) construct. The specimens were then tested using a materials testing machine, determining initial superior and axial displacements with a preload, and then cyclically loaded in the axial direction with 70 N for 5000 cycles. Displacement was again measured with the same preloads at fixed cycle intervals. The specimens were then loaded superiorly to failure.

RESULTS

At 5000 cycles, the mean axial displacement was 1.7 mm for the DB group and 1.2 mm for the DE group (P = .19), and the mean superior displacement was 1.1 mm for the DB group and 0.7 mm for the DE group (P = .32). Load at failure was similar (558 N for DE, 552 N for DB; P = .96). There was no statistically significant difference in the modes of failure.

CONCLUSION

Biomechanical testing of both constructs showed similar fixation stability after cyclical axial loading and similar loads to failure.

CLINICAL RELEVANCE

The strength of both constructs after cyclical loading in the axial plane and load-to-failure testing in the superior plane validate their continued clinical use for achieving stability in AC joint reconstruction procedures.

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

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

Rockwood grade I and II acromioclavicular injuries: as benign as commonly believed?

The acromioclavicular (AC) joint is the articulation between the distal clavicle and the acromion process of the scapula. As the upper limb moves, passive motion of the AC joint occurs in three planes, with the AC and coracoclavicular ligaments providing stability. Injuries are common, particularly during contact sports, and are classified using Rockwood's system. Grade I (sprain) and II (rupture) injuries only affect the AC ligaments and are generally managed conservatively. However, recent reports have indicated that long-term outcomes after these injuries are poor, perhaps due to an inadequate period of immobilization preventing complete ligamentous healing.

Acute high-grade acromioclavicular dislocations treated with triple button device (MINAR): Preliminary results

OBJECTIVE

Describe the clinical and radiological results of triple button device in the treatment of high-grade AC dislocations (Rockwood, type V) and assess whether improves vertical and horizontal stability compared to the techniques previously described.

MATERIAL AND METHODS

This retrospective study included 39 patients with type V acromioclavicular dislocations treated with Twin Tail TightRope™ system (triple button device). Of the 39 patients, 33 (26 men and 7 women) were able to participate in clinical and radiographic follow up. At the time of surgery, the mean age was 25years±7(range, 17-49). All patients underwent bilateral-weighted Zanca (CC distance) and Alexander view (AC distance) as well as the Constant Score (CS) and Acromioclavicular Joint Instability Scoring System (ACJI). Radiological and clinical outcome was assessed during routine follow-up examinations preoperatively, postoperatively, 1, 3, 6 months and every year after the surgery. The presence of calcification, degenerative changes, mobilization of implants and bone resorption were also assessed.

RESULTS

After a mean follow up of 25±4months (range 14-38), the results of the Constant (CS) were 94.1±5,5 (range 76-100) and test ACJI 87.3±9,8 (range 65-100), showing no significant differences with the uninjured shoulder (CS 95.8±2.5, range 83-100; ACJI 94.1±3.7, range 80-100). At final review, we observed that preoperative coracoclavicular distance (Zanca View) improved from 21,75±1.97mm to 8,73mm±0.75 and the acromioclavicular distance (Alexander View) from 12,65mm±1.99 to 0,35±0.3mm. Compared with healthy shoulder, these differences were not significant. There was no loss of reduction with this system in the vertical plane. 4 patients (12.12%) revealed signs of posterior instability with worse clinical test results. The presence of degenerative joint changes (6,06%), calcifications (27,2%) or mobilization of the implant (18,18%) was not associated with worse clinical outcomes.

CONCLUSION

Twin Tail device using minimally invasive technique improves stability in the vertical and, specially in the horizontal plane relative to the previously described techniques without increasing number of complications.

[Arthroscopically assisted techniques for treatment of acute and chronic acromioclavicular joint injuries]

Acute and chronic acromioclavicular (AC) joint dislocation is frequently encountered in the routine clinical practice. This injury can lead to significant impairment of shoulder girdle function. Therapy based on the severity of injury is recommended to re-establish correct shoulder function. The static radiographic Rockwood classification is used to define the degree of dislocation but the clinical aspects and functional x-ray imaging of horizontal AC joint instability should also be considered for selection of the appropriate procedure. Rockwood grades I and II injuries are treated non-operatively with early functional exercise. The approach for Rockwood grade III injuries should be individual and patient-specific, with non-surgical procedures for low functional requirement patients with a high risk for surgical interventions. For patients with high demands on shoulder function surgery is recommended. A detailed diagnostic assessment frequently reveals Rockwood grade III injuries to be type IV injuries. Rockwood types IV and V AC joint dislocations require surgery for sustained stability. Treatment of acute injuries is recommended within 1-3 weeks after trauma but there is no clear evidence of a cut-off for the presence of chronic injuries. Various surgical techniques have been described in the literature. This article presents an arthroscopically assisted technique that addresses both vertical and horizontal instability of the AC joint.

Arthroscopically Assisted Acromioclavicular and Coracoclavicular Ligament Reconstruction for Chronic Acromioclavicular Joint Instability

Acromioclavicular (AC) joint injuries are common injuries, especially in the young and active, male population. AC joint injuries account for 12% of all injuries of the shoulder girdle in the overall population. Although conservative treatment is recommended for Rockwood type I and type II injuries, there is controversial debate about optimal treatment for type III injuries. High-grade injuries are typically treated operatively to avoid painful sequelae. A vast number of different surgical methods have been described over the past few decades. Recent advances in arthroscopic surgery have enabled the shoulder surgeon to treat acute and chronic AC lesions arthroscopically assisted. Clinical studies have already shown good and reliable results. Although surgeons agree that a biological augmentation is required to minimize the risk of recurrent instability in chronic cases, a gold standard still needs to be defined. We present an arthroscopically assisted biological augmentation technique to reconstruct the AC and coracoclavicular ligaments, protected by a button-suture tape construct for chronic AC joint instability. The presented arthroscopic biological augmentation technique uses less and/or smaller drill holes in the clavicle and coracoid than previously described, thus reducing weakening of the bony structures. At the same time it enhances both horizontal and vertical stability.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Midterm results of coracoclavicular stabilization with double augmentation for acute acromioclavicular dislocation

Introduction

Numerous techniques have been introduced for the treatment of acute acromioclavicular (AC) joint dislocation. We aim to report the midterm results of coracoclavicular (CC) stabilization with double augmentation for the acute AC joint dislocation.

Case description

Forty-three patients who underwent surgery for acute AC joint dislocation were followed up for an average of 59.6 months (range 40–97). The study composed of two treatment groups: group S, with 25 patients, in whom two suture anchors were used; and group B, with 18 patients, in whom a suture anchor and a double flip-button device were used, however the techniques in both groups are based on the same principle which is double augmentation. Postoperative evaluations were made retrospectively, clinically, and radiographically.

Discussion and Evaluation

At the last follow-up, the mean Constant score was 91.2 (range 74–100) and the UCLA scale was 31.4 (range 24–35). The overall ratio of the CC distance in the injured shoulder to that in the uninjured shoulder, expressed as a percentage, significantly decreased, to 93.4 ± 22.7 %, immediate postoperatively, and significantly increased, to 113.8 ± 23.4 %, at the final follow-up. Complete reduction of the AC joint was achieved in 34 patients (79.1 %), and 8 patients (18.6 %) exhibited a slight loss of reduction, although their functional outcomes were good.

Conclusions

The results of this study provide evidence that double augmentation is effective in the treatment of acute AC dislocation.

Level of evidence

Therapeutic study, case series, Level IV.

Functional Outcomes of Type V Acromioclavicular Injuries With Nonsurgical Treatment

INTRODUCTION

This study investigated nonsurgical management of type V acromioclavicular (AC) injuries to determine functional outcomes and to attempt to identify factors associated with positive results.

METHODS

In a retrospective chart review, patients with radiographic and clinical evidence of type V AC injuries per the Rockwood classification were included in the study. Patients treated nonsurgically for ≥6 months were considered eligible for analysis. Functional outcomes were assessed using Disabilities of the Arm, Shoulder, and Hand (DASH) and American Shoulder and Elbow Surgeons (ASES) scores.

RESULTS

Twenty-two patients with a mean age of 42.2 ± 12.8 years were included in the study. The average coracoclavicular distance at the time of presentation was 26.3 mm (+199%). Mean DASH and ASES scores were 27.8 ± 17.7 and 62.8 ± 17.1, respectively, at an average of 34 months from the time of injury. Patients with normal DASH (≤10) and ASES (>92) scores were younger than those with abnormal scores. At final assessment, 77% of the patients were currently working, with nine patients performing manual labor.

CONCLUSION

Following nonsurgical management of type V AC injuries, most patients are able to return to work but have limited functional outcome scores. A small subset of patients with type V AC injuries can achieve normal functional outcomes with nonsurgical management.

LEVEL OF EVIDENCE

Level IV, Case Series.

The Orientation and Variation of the Acromioclavicular Ligament: An Anatomic Study

BACKGROUND

Several biomechanical studies have shown that the acromioclavicular (AC) ligament prevents posterior translation of the clavicle in the horizontal plane. In anatomy textbooks, however, the AC ligament is illustrated as running straight across the AC joint surface.

HYPOTHESIS

The AC ligament does not run straight across the joint surface, and the configuration of the AC ligament may vary.

STUDY DESIGN

Descriptive laboratory study.

METHODS

We used 16 pairs of shoulder girdles in this study. After identifying the AC ligament, we macroscopically investigated the orientation and attachment of the ligament and measured the angle between the ligament and the line perpendicular to the AC joint surface by using a digital goniometer. In addition, the AC joint inclination angle was measured, and the Spearman rank correlation coefficient between the joint inclination and the ligament angle was calculated. Finally, we sought to classify the AC ligament based on its configuration. Of the 16 pairs of specimens, 3 pairs of shoulders were histologically examined.

RESULTS

The AC ligament was divided into 2 parts: a bundle at the superoposterior (SP) part and a bundle at the anteroinferior (AI) part of the joint. The well-developed SP bundle was consistent and ran obliquely at an average ± SD 30° ± 6° in relation to the AC joint surface, from the anterior part of the acromion to the posterior part of the distal clavicle. The joint inclination was 70° ± 12°, and a negative moderate correlation was found between the joint inclination and the ligament angle (P = .02, r = -0.46). In comparison, the AI bundle was thin and narrow, and it could be categorized into 3 types according to its various configurations.

CONCLUSION

The AC ligament could be separated into the SP bundle and the AI bundle. The SP bundle ran posteriorly toward the distal clavicle from the acromion at an average angle of 30° to the joint surface.

CLINICAL RELEVANCE

Anatomic reconstruction, based on the current findings in combination with findings regarding the coracoclavicular ligament, could facilitate improved outcome in the treatment of AC joint disruption.

Shoulder acromioclavicular joint reconstruction options and outcomes

Acromioclavicular joint separations are a common cause of shoulder pain in the young athletic population. In high-grade injuries, acromioclavicular joint reconstruction procedures may be indicated for functional improvement. There is currently no gold standard for the surgical management of these injuries. Multiple reconstructive options exist, including coracoclavicular screws, hook plates, endobutton coracoclavicular fixations, and anatomic ligament reconstructions with tendon grafts. This article aims to review pertinent acromioclavicular joint anatomy and biomechanics, radiographic evaluation, classification system, as well as reconstruction options, outcomes, and complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Anatomical principles for minimally invasive reconstruction of the acromioclavicular joint with anchors

PURPOSE

The aim of this study was to evaluate the outcome of a minimally invasive surgical technique for the treatment of patients with acromioclavicular joint dislocation.

METHODS

Sixteen patients with complete acromioclavicular joint dislocation were enrolled in this study. All patients were asked to follow the less active rehabilitation protocol post-operatively. Computed tomography with 3-D reconstruction of the injured shoulder was performed on each patient post operatively for the assessment of the accuracy of the suture anchor placement in the coracoid process and the reduction of the acromioclavicular joint. Radiographs of Zanca view and axillary view of both shoulders were taken for evaluating the maintenance of the acromioclavicular joint reduction at each follow-up visit. The Constant shoulder score was used for function assessment at the final follow-up.

RESULTS

Twenty seven of the 32 anchors implanted in the coracoid process met the criteria of good position. One patient developed complete loss of reduction and another had partial loss of reduction in the anteroposterior plane. For the other 14 patients, the mean Constant score was 90 (range, 82-95). For the patients with partial and complete loss of reduction, the Constant score were 92 and 76 respectively. All of them got nearly normal range of motion of the shoulders and restored to pre-operative life and works.

CONCLUSION

With this minimally invasive approach and limited exposure of the coracoid, a surgeon can place the suture anchors at the anatomical insertions of the coracoclavicular ligament and allow the dislocated joint reduced and maintained well.

LEVEL OF EVIDENCE

Level IV, Case series; therapeutic study.

Long-term outcomes of tension band wiring with a single K-wire in Rockwood type IV/V acute acromio-clavicular dislocations: 25 cases

BACKGROUND

Our objective was to evaluate the long-term functional and radiological outcomes of tension band wiring with a single K-wire for acute Rockwood types IV and V acromio-clavicular dislocation (ACD).

METHODS

Single-centre cross-sectional non-randomised observational cohort study of 25 shoulders treated surgically between January 2002 and December 2004, in 25 patients, 23 males and 2 females, with a mean age of 35±11years (24-46). The evaluation criteria were the absolute and weighted Constant scores, QuickDASH score, subjective shoulder value (SSV), visual analogue scale (VAS) pain score at rest and during activities, and radiographic features in clinically symptomatic patients.

RESULTS

Mean values were as follows: follow-up, 150±17months (133-167); absolute Constant score, 88±17 (71-105); weighted Constant score, 92.5±12.5 (80-105); QuickDASH, 15.5±7 (8.5-22.5); SSV, 88±17% (71-105); VAS pain score at rest, 0.2±0.7 (0-0.9); and VAS pain score while active, 1.4±2.3 (0-3.7). The weighted Constant score was less than 70% in only 8% of patients. Of the 17 patients for whom radiographs were obtained, 8 had acromio-clavicular osteoarthritis. Mean coraco-clavicular distance was 12.3±4.3mm (8-16.6) and mean acromio-clavicular distance was 5±5mm (0-10). The recurrence rate was 8%.

CONCLUSION

Tension band wiring with a single K-wire for acute acromio-clavicular dislocation reliably provides good long-term functional outcomes. Recurrences are uncommon and few patients experience symptoms (8%).

LEVEL OF EVIDENCE

IV, retrospective study.

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

AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

TAKE HOME MESSAGE

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