Arthroscopic treatment of acute acromioclavicular joint dislocation by coracoclavicular ligament augmentation

Outcomes of arthroscopic coracoclavicular management for acromioclavicular joint injuries: A systematic review

Introduction

Various surgical procedures for coracoclavicular (CC) ligament repair have been described for symptomatic acromioclavicular joint dislocations, with none emerging as a clear gold standard. There has been increased interest in arthroscopic approaches. This systematic review evaluates clinical outcomes after arthroscopic surgeries used to treat chronic and acute AC joint dislocations.

Methods

We searched three databases (PubMed, EMBASE, and OVID [MEDLINE]) from database inception to December 20, 2022. Studies were included if they met the following criteria: studies evaluating humans, English language studies, level of evidence I to IV, and studies investigating clinical outcomes in patients following arthroscopic surgery for coracoclavicular ligament reconstruction. Studies on open reconstruction techniques only were excluded. Primary outcomes included function/pain scores, coracoclavicular distances, complications, and revision rates.

Results

Fifty-two studies were included. In 33 studies, postoperative Constant-Murley scores ranged from 82.8 to 99 points. Postoperative VAS scores ranged from 0.3 to 4.1 in 16 studies. In 46 studies, revision rates ranged from 0 % to 44.4 %. We did not observe a difference in revision rates between chronic and acute cases (P = 0.268). Complications were more common in chronic than acute cases (25.5 % vs. 16.4 %; P < 0.001).

Conclusions

Arthroscopic surgery for chronic and acute CC ligament injuries exceeds the MCID and PASS for several outcomes, with low failure rates. Arthroscopic CC reconstruction is a safe and effective alternative for chronic AC joint dislocations.

Level of evidence

IV (Systematic Review of Level I-IV Studies).

Choice of Acromioclavicular Dislocation Treatment Should Not Be Influenced by Risk of Development of Acromioclavicular Osteoarthritis: A Systematic Review With Meta-Analysis

BACKGROUND

It is currently unknown to what degree surgical or nonoperative treatment of acromioclavicular (AC) dislocation influences the development of osteoarthritis (OA). The aim of this study was to evaluate AC OA after surgical and nonoperative treatment for AC dislocations, compare OA prevalence between treatment options, and compare OA prevalence between the injured and contralateral shoulder.

METHODS

Articles reporting on the prevalence of OA after surgical or nonoperative treatment of an AC dislocation with a minimal 2-year follow-up were included. AC OA presence was extracted for the injured and contralateral shoulder. Treatment categories were defined based on anatomical variation in the reattachment of ligaments: AC fixation, coracoclavicular (CC) fixation, AC and CC fixation, Bosworth screw synthetic graft, tendon graft, and conservative. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Ninety-four articles were included for qualitative analysis, and 7 articles were included for meta-analysis (n = 3,812; follow-up = 2.0-24.2 years; mean age 37.6 ± 10.4 years). A total of 3,483 patients underwent surgical treatment, and 329 patients underwent conservative treatment. OA prevalence ranged from 6.7%-29.3% between 7 pooled treatment categories. Most included studies had a follow-up <10 years (94%) and OA prevalence increased with time, regardless of treatment option. There was no difference in OA prevalence between the injured and contralateral shoulder (p = 0.120). MINORS scores were varied, ranging from poor to very good.

CONCLUSION

The pooled AC OA prevalence of the 7 treatment categories ranged from 6.7% for the CC fixation surgical group to 29.3% for the conservative treatment group. However, the included studies were predominantly of low quality and had varying follow-up periods, with most having relatively short follow-up durations. No difference in AC OA prevalence was found between the injured and contralateral shoulder. Based on the available evidence, treatment choice for AC dislocation should not be influenced by the potential development of AC AO.

LEVEL OF EVIDENCE

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

Modified Weaver Dunn Versus Ligamentous Reconstruction Grafts in Chronic Acromioclavicular Joint Dislocation: A Systematic Review and Meta-Analysis of Comparative Studies

Background

Acromioclavicular (AC) joint trauma is a frequent sports injury. Modified Weaver Dunn (MWD) is a commonly used technique to address this injury. However, tendinous grafts (Autogenous Palmaris Longus or Semitendinosus tendons) are increasingly being used due to the biologic weakness of MWD.

Methods

Three search was done until January 2024 with data extraction consisting of adverse events (infections and failures), Constant-Murley score, American Shoulder and Elbow Surgeons score, and postoperative coracoclavicular distance.

Results

Four studies were included in this metaanalysis. Tendinous graft was shown to have statistically better ASES and Constant-Murley scores. Furthermore, there were no difference in adverse events, and postoperative coracoclavicular distance.

Conclusion

The tendinous graft showed no differences in adverse events, and postoperative coracoclavicular distance when compared to modified Weaver Dunn. However, it showed higher postoperative ASES and Constant-Murley score without analysis of the minimal clinical important difference making the difference solely statistical.

Level of evidence

3.

A Modified Endoscopic Technique with Three Incisions for Rockwood Types III and V Acromioclavicular Joint Dislocation

OBJECTIVE

Acromioclavicular joint dislocation is one of the most common shoulder injuries in young men. With the advancement of minimally invasive technology, arthroscopy of acromioclavicular joint dislocation has been recognized for its good curative effect. This study aimed to explore the technical details and clinical efficacy of a modified minimally invasive endoscopic treatment for acromioclavicular joint dislocation.

METHODS

Clinical data of patients receiving the three-incision endoscopic treatment were retrospectively reviewed between July 2013 and July 2019. A total of 72 patients with acromioclavicular joint dislocation of Rockwood type III (n = 42) and type V (n = 30) were included in this study. Postoperative routine radiography was performed to evaluate acromioclavicular joint reduction and fixation. In addition, functional recovery of the shoulder joint was assessed using the American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores. Differences between the preoperative and postoperative data were compared using paired t-tests.

RESULTS

All patients underwent loop plate elastic fixation under endoscopy during 24 to 48 months of follow-up. Postoperative radiography showed that the acromioclavicular joint achieved anatomical reduction. The ASES score (91.1 ± 4.2) was significantly improved compared to the preoperative ASES score (62.4 ± 3.1) (t = 46.65, P < 0.0001). The Constant-Murley score (93.1 ± 4.6) was also significantly higher than that before the operation (40.7 ± 6.4) (t = 56.41, P < 0.0001). No postoperative complications occurred. During follow-up, four patients had mild acromioclavicular joint degeneration but no obvious pain symptoms.

CONCLUSION

The modified three-incision endoscopic technique optimizes the surgical incision, reduces trauma, is minimally invasive, and provides rapid rehabilitation with satisfactory clinical outcomes.

Acromioclavicular joint stabilization with a double cow-hitch technique compared to a double tight-rope: a biomechanical study

INTRODUCTION

The aim of the present biomechanical study was to evaluate the stability of a novel simple and cost-effective mini-open double cow-hitch suture button technique of acromioclavicular (AC) joint stabilization in comparison to a well-established double tight-rope technique.

MATERIALS AND METHODS

A total of 12 fresh-frozen cadaveric shoulders were randomized into two treatment groups. In either a coracoclavicular stabilization with a standard double tight-rope technique (Group 1; n = 6, age 78 years ± 10) or a double cow-hitch with two No. 5 FiberWire strains looped in a bicortical button placed at the bottom of the coracoid process (Group 2; n = 6, age 80 years ± 13). Both techniques were equally augmented with an AC joint cerclage using a FiberTape. All shoulders were tested in a servo-hydraulic material testing machine for elongation/cyclic displacement (in mm) after cyclic loading (70 N cyclical load, 1500 cycles), stiffness (N/mm) and ultimate load to failure (N). The mechanism of failure was recorded. All tests were performed in a previously published testing setup.

RESULTS

After 1500 cycles, group 2 showed a cyclic displacement of 1.67 mm (SD 0.85), compared to 1.04 mm (SD 0.23) cyclic displacement in group 1 (p = 0.11). The cyclic displacement after AC reconstruction in group 1 was 0.36 mm lower than in the native state with intact ligaments (p = 0.19), whereas the cyclic elongation in group 2 was 0.05 mm higher compared to the native situation (p = 0.87). Stiffness after reconstruction was significantly higher in group 1 compared to the native specimen (p = 0.001), in group 2 it was similar as before the reconstruction (p = 0.64). Ultimate load to failure and stiffness were higher in group 1 with 424 N (SD 237) and 68.6 N/mm (SD 8.2), compared to 377 N (SD 152) and 68 N/mm (SD 13.3) in group 2, without reaching statistical significance (p = 0.69 and 0.89). The most common failure modes were clavicular fractures at the tight rope drill holes (n = 2) and clavicular fractures medially at the fixation site (n = 2) in group 1, and coracoid button break-through (n = 3) and clavicular fractures medially at the fixation site (n = 2) in group 2.

CONCLUSIONS

Stabilization of the AC joint with a novel mini-open double cow-hitch suture button technique resulted in a similar low elongation, high stiffness and ultimate load to failure compared to a double tight-rope technique. This cost-effective technique for AC joint stabilization could demonstrate a sufficient biomechanical stability with especially high stiffness and load-to-failure.

LEVEL OF EVIDENCE

Biomechanical study.

Criteria for return to play after operative management of acromioclavicular joint separation: a systematic review

Background

Acromioclavicular (AC) joint separation is a common cause of shoulder injury among athletes. High-grade injuries may require operative fixation, and comprehensive return-to-play guidelines have not yet been established. The purpose of this study was to summarize criteria for return to play after operative management of AC joint separation.

Methods

A systematic review of the literature was performed from January 1999 to April 2020 to evaluate clinical evidence regarding criteria for return to play after operative management of isolated AC joint separation.

Results

Sixty-three studies with at least 1 explicitly stated return-to-play criterion were identified out of an initial database search of 1253 published articles. Eight separate categories of return-to-play criteria were identified, the most common of which was time from surgery (95.2%). Return-to-play timelines ranged from 2 to 12 months, the most common timeline being 6 months (37.8%). Only 4 (6.3%) studies used conditional criteria to guide return to play, which included range of motion, strength, clinical stability, radiographic stability, functional assessment, safety assessment, and hardware removal.

Conclusion

Most published studies use only time-based criteria for return to play after surgery for AC joint separation, and only a small number of studies use additional subjective or objective criteria. While this systematic review helps provide a foundation for developing a comprehensive return-to-play checklist, further investigation is needed to establish safe and effective guidelines that will enable athletes to safely return to sport and minimize the recurrence of injury.

The prevalence of intraarticular associated lesions after acute acromioclavicular joint injuries is 20%. A systematic review and meta-analysis

PURPOSE

To synthesise the evidence on the prevalence of associated intraarticular lesions in subjects with acute acromioclavicular joint (ACJ) dislocations.

METHODS

A search in two electronic databases (PUMBMED and EMBASE) was performed from 1985 to 2019. Two independent reviewers selected studies that complied with the following inclusion criteria: (1) the study included data on surgically treated ACJ dislocation grade III-V in the Rockwood classification, (2) the ACJ injuries were acute (the surgery was performed less than 6 weeks after injury), (3) an arthroscopic evaluation of the glenohumeral joint was performed during surgery. The quality of the studies included was assessed using the tool of the Joanna Briggs Institute.

RESULTS

A total of 47 studies with acute ACJ injuries met the initial inclusion criteria. Of these, 21 studies (9 retrospective case series, 9 prospective case series and 3 retrospective cohort studies) presented data on associated intraarticular lesions amenable for use in the meta-analysis. The meta-analysed studies included a total of 860 subjects with acute ACJ dislocations with a male/female ratio of 6.5 and a mean age of 32 years. The meta-analysis showed a prevalence of associated intraarticular lesions in subjects with acute ACJ of 19.9% (95% confidence interval [CI] 14.0-26.4%; 21 studies, 860 analysed participants; P = 0.000; I²: 74.5% random-effects model; low risk of bias).

CONCLUSION

One in five subjects with surgically treated acute ACJ dislocations will have an associated intraarticular lesion that requires further intervention. The case for a customary arthroscopic evaluation of the joint, even when an open procedure is performed to deal with the ACJ dislocation, is strong. Level of evidence IV Trial registry Systematic review registration number: PROSPERO CRD42018090609.

Biologic and synthetic ligament reconstructions achieve better functional scores compared to osteosynthesis in the treatment of acute acromioclavicular joint dislocation

PURPOSE

To systematically review the outcomes of surgical treatments of acute acromioclavicular joint dislocation.

METHODS

Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of acute acromioclavicular joint dislocations were included. Following data were extracted: authors and year, study design, level of evidence, number of patients, age, classification of acromioclavicular joint dislocation, time to surgery, surgical technique, follow-up, clinical and imaging outcomes, complications, and failures. Descriptive statistics was used, when a data pooling was not possible. Comparable outcomes were pooled to generate summary outcomes reported as frequency-weighted values. Quality appraisal was assessed through the MINORS checklist.

RESULTS

One hundred and thirty-three studies were included for a total of 4473 shoulders. Mean age of participants was 36.9 years. Mean follow-up was 42.06 months. Arthroscopy showed better ASES (p < 0.0001) and lower VAS pain score (p = 0.0249) compared to an open approach. Biologic and synthetic reconstructions demonstrated better results over osteosynthesis techniques. Biologic techniques showed overall better Constant (p = 0.0001) and DASH (p = 0.0215) scores, while synthetic reconstruction showed better UCLA score (p = 0.0001). Among suture buttons, triple button showed overall better results in Constant (p = 0.0001) and VAS (p = 0.0001) scores, while better results in DASH score (p = 0.0003) were achieved by 2 double button techniques. Overall, the level of evidence was low.

CONCLUSION

Biological and synthetic reconstructions achieved better functional scores compared to osteosynthesis. Among suture buttons, the triple button showed better functional performance.

LEVEL OF EVIDENCE

IV.

Arthroscopic Coracoclavicular Ligament Stabilization Using Coracoid Cortical Suspension in Acute Acromioclavicular Joint Injury; Precision of Drill Tunnel

Acute acromioclavicular joint separation is a common injury of the shoulder. There are several methods for treating this condition; however, there is no gold standard established. Herein, we propose an arthroscopic method for the treatment of acute acromioclavicular joint separation using a simple cortical suspension device at the coracoid base via a transclavicular-transcoracoidal tunnel and tieing the suture at the clavicle. This method has the advantages of making a precision drilling tunnel using small implants and small stab incisions, with better cosmetic results and less implant irritation.

Low prevalence of relevant associated articular lesions in patients with acute III-VI acromioclavicular joint injuries

PURPOSE

To define the prevalence of associated articular injuries in patients with severe (Rockwood's III-VI) acute acromioclavicular joint injuries and to find out how many of these were associated with the traumatic event and required surgical treatment.

METHODS

Retrospective observational multicentric study performed in ten centres included patients who required surgery for acute acromioclavicular joint injuries between 2010 and 2017. The inclusion criteria were: presence of an acute acromioclavicular joint injury (grades III-IV-V-VI) and surgical treatment within 3 weeks of injury that included a full arthroscopic evaluation of the shoulder. Basic epidemiological data, severity of the original injury, prelesional sport level and prelesional work site requirements were recorded. The presence of intraarticular glenohumeral lesions and information of their characteristics, treatment, and whether each lesion was considered acute or pre-existing was also recorded.

RESULTS

Two-hundred one subjects [mean (SD) age 36.7 (11.7) years] with acute acromioclavicular joint injuries (110 Rockwood type III, 34 type IV, 56 type V and 1 type VI) fulfilled the inclusion criteria. A total of 28 (13.9%) associated articular lesions were found. These lesions were more often found in grade IV injuries (26.5% in grade IV vs 11.4% in grade III, p = 0.037) and presented in males (18.7% in males vs 4% in females, p = 0.015). Age, laterality, sport level or work requirements did not affect the prevalence of associated lesions. Twelve were rotator cuff tears (6 PASTA lesions, 3 partial supscapularis tears, 2 bursal supraspinatus tears and 1 full-thickness supraspinatus tear), 16 were labral tears (9 anterior, 1 posteroinferior and 6 SLAP). Only 14 (50% of lesions, 7% of total subjects) were considered acute and all but one (an SLAP type 2 tear) required further surgical attention. Most pre-existing lesions were left untreated (n = 7) or managed with minimal debridement (n = 6), and only two required further surgery. The prevalence of associated lesions that required surgical management was 7.46%.

CONCLUSIONS

The prevalence of relevant associated lesions in subjects with acute grade III to VI ACJI is relatively low. Only 14% of subjects have an associated lesion and only half of these required further surgical attention.

LEVEL OF EVIDENCE

Retrospective case series, level IV.

A New Coracoclavicular Guider for Minimally Invasive Anatomic Coracoclavicular Reconstruction with Two TightRope Systems in Acute Acromioclavicular Joint Dislocation

High-grade injuries of complete acromioclavicular (AC) joint disruption (types IV - VI) are typically treated surgically. Since the coracoclavicular (CC) ligament is most often used for stabilizing the AC joint, most reconstruction techniques to treat dislocation of this joint rely upon CC interval fixation. A TightRope system is usually used to augment the CC ligament to treat acute AC dislocations with arthroscopic assistance. The conventional arthroscopic technique employing one TightRope system is associated with some complications, including anterior subluxation of the clavicle and clavicular bony avulsion as a consequence of rotational movements. As an alternative, two TightRope systems can be used to anatomically reconstruct the CC ligament to avoid these complications. We present a new CC guider with which the surgeon can replicate the native CC ligament complex orientation using two TightRope systems via two minimally invasive incisions without arthroscopic assistance. This procedure relies upon the accommodation and stable placement of the clavicle and coracoid bone tunnels for the two TightRope systems in place of the trapezoid and conoid of the CC ligament. We retrospectively reviewed the outcomes for 16 patients with acute dislocation of the AC joint that had been treated by a single surgeon using a double-button fixation system. An independent reviewer conducted functional testing of these patients, including the use of Disability of Arm, Shoulder and Hand (DASH), Constant and visual analog scale (VAS) scores. Standard radiographs were used for assessing the CC distance for the impacted shoulder relative to that of the unaffected contralateral shoulderThe new CC guider leads to an excellent cosmetic result. Our clinical results show that this technique can be easily performed and is similarly invasive to other current arthroscopic techniques.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III, Case series.

Outcome of arthroscopy-assisted treatment for distal clavicle fractures

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV, Case series, Treatment study.

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.

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.

A Biomechanical Analysis of Different Clavicular Tunnel Diameters in Anatomic Acromioclavicular Ligament Reconstruction

PURPOSE

To evaluate the biomechanical stability of a tendon-to-clavicle bone interface fixation of a graft in revision acromioclavicular reconstruction.

METHODS

Fifteen fresh-frozen cadaveric shoulders were used. All specimens underwent bone density evaluation. For the primary reconstruction, a 5-mm semitendinosus allograft was inserted into a 5-mm bone tunnel at 25 and 45 mm from the lateral end of the clavicle using a 5.5 × 8-mm PEEK (polyether ether ketone) tenodesis screw. Each single graft was fixed in a cryo-clamp and cyclically loaded from 5 to 70 N for 3,000 cycles, followed by load-to-failure testing at a rate of 120 mm/min to simulate the revision case. To simulate tunnel widening, the tunnels of the revision series were over-drilled with an 8-mm drill, and a 5-mm semitendinosus graft with an 8 × 12-mm PEEK tenodesis screw was inserted. Biomechanical testing was then repeated.

RESULTS

The bone mineral density analysis showed a significantly higher density at the 45-mm hole compared with the 25-mm hole (P = .001). The ultimate load to failure increased from the 5.5-mm screw to the 8-mm screw at the 45-mm hole position (P = .001). There was no statistically significant difference at the 25-mm hole position (P = .934). No statistical significance for graft elongation comparing the 5.5-mm screw and the 8-mm screw at the 25-mm (P = .156) and 45-mm (P = .334) positions could be found.

CONCLUSIONS

Comparable biomechanical stability for the tendon-to-bone interface fixation in different clavicular tunnel diameters simulating primary and revision reconstruction was achieved.

CLINICAL RELEVANCE

There is a lack of literature regarding revision acromioclavicular joint reconstruction, but our biomechanical results show comparable stability to primary reconstruction. These data provide support for the use of anatomic acromioclavicular ligament reconstruction in revision cases.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

Transarticular fixation by hook plate versus coracoclavicular stabilization by single multistrand titanium cable for acute Rockwood grade-V acromioclavicular joint dislocation: a case-control study

BACKGROUND

Hook plate (HP) is popularly used for acute and severely displaced acromioclavicular (AC) dislocations. However, subacromial impingement and acromion osteolysis induced by transarticular fixation are notorious. The current case-control study was to compare transarticular fixation by HP to coracoclavicular (CC) stabilization by single multistrand titanium cable (MSTC).

METHODS

Between January 2006 and August 2009, 24 patients with acute AC dislocations were surgically treated by open reduction and transarticular fixation with HP. These patients were matched to a series of 24 patients, who were managed by CC stabilization with MSTC in the same period. All AC dislocations were graded as Rockwood type V. Implant was removed 8-12 months after the primary operation in all patients, and 12 months at least were needed to assess the maintenance of AC joint. Functional results were evaluated before implant removal as well as in the last follow-up based on Constant-Murley criteria.

RESULTS

There were no differences of demographic data including age, dominant gender and side, injury-to-surgery interval, operation time and follow-up period. In terms of functionality, Constant score was 95.8 ± 4.1 in MSTC group, while 76.7 ± 8.0 in HP group before implant removal (P < 0.001). In detail, MSTC was superior to HP in pain, ROM and activities. Constant score was significantly improved to 86.1 ± 5.7 after hardware removal for patients in HP (P < 0.001). Degenerative change of acromioclavicular joint presented in 16 patients (66.7%) in patients treated by HP, while it was found in only 3 patients (12.5%) treated by MSTC (P < 0.001).

CONCLUSIONS

MSTC is superior to HP for the treatment of Rockwood type-V acromioclavicular dislocation both before and after removal of the implant. Hardware removal is of great benefits for functional improvement in patients treated by HP.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

The treatment of type III acromioclavicular dislocations with a modified Cadenat procedure: surgical technique and mid-term results

INTRODUCTION

The treatment of type III acromioclavicular injuries is controversial. Both conservative and surgical approaches have been successful. Aim of the present study was to prospectively evaluate the results of the modified Cadenat procedure in subjects with type III acromioclavicular joint injuries.

METHODS

Twenty-eight patients with acute type III acromioclavicular joint dislocations (mean age 31 years) were prospectively enrolled in the present study. The delay between the injury and the surgery varied between 4 and 19 days, with an average of 8.3 days. All patients were evaluated both preoperatively and postoperatively with radiographs and clinically with visual analog scale and Constant score. A modified Cadenat procedure was performed in all cases.

RESULTS

Twenty-five patients were evaluated at an average follow-up of 72 months. One patient had a re-dislocation 3 years after surgery. At the last follow-up, average visual analog scale score of was 0.96 (range 0-3), while mean constant score was 94.32 (range 90-99) and 92 % of patient were very happy or happy with their functional result. Radiographs showed complete reduction in 22 patients and loss of reduction in two cases. No major complications were recorded.

INTERPRETATION

This is the first clinical report on a modified Cadenat procedure. This operation has a reduced morbidity if compared to other techniques involving autologous grafts. Moreover, it yielded good functional results, with complete pain relief, and full strength recovery at mid-term follow-up. No major loss of reduction or recurrence of instability was observed.

LEVEL OF EVIDENCE

4, Case series.