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

Return to Play After Surgical Treatment for Acromioclavicular Joint Dislocation: A Systematic Review

BACKGROUND

Acromioclavicular (AC) joint dislocation is a common clinical problem among young and athletic populations. Surgical management is widely used for high-grade dislocations (Rockwood III-VI) and in high-demand athletes at high risk of recurrence.

PURPOSE

To systematically review the evidence in the literature to ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after surgical treatment for AC joint dislocation.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted in the PubMed database. Clinical studies were eligible for inclusion if they reported on RTP after surgical treatment for AC joint dislocation. Statistical analysis was performed with SPSS.

RESULTS

We found 120 studies including 4327 cases meeting our inclusion criteria. The majority of patients were male (80.2%), with a mean age of 37.2 years (range, 15-85) and a mean follow-up of 34.5 months. Most were recreational athletes (79%), and the most common sport was cycling. The overall rate of RTP was 91.5%, with 85.6% returning to the same level of play. Among collision athletes, the rate of RTP was 97.3%, with 97.2% returning to the same level of play. In overhead athletes, the rate of RTP was 97.1%, with 79.2% returning to the same level of play. The mean time to RTP was 5.7 months (range, 1.5-15). Specific RTP criteria were reported in the majority of the studies (83.3%); time to return to play was the most commonly reported item (83.3%). Type III Rockwood injuries had the highest RTP rate at 98.7% and the earliest RTP at 4.9 months. Among the different surgical techniques, Kirschner wire fixation had the highest rate of RTP at 98.5%, while isolated graft reconstruction had the earliest RTP at 3.6 months.

CONCLUSION

The overall rate of RTP was reportedly high after surgical treatment for AC joint dislocation, with the majority of patients returning to their preinjury levels of sport. There is a lack of consensus in the literature for what constitutes a safe RTP, with further focus on this topic required in future studies.

Mini-open vs. arthroscopic double tight-rope reconstruction after acute AC-joint dislocation: a comparison in functional outcome and sports activity

INTRODUCTION

In athletes, acromioclavicular joint disruptions account for up to 50% of all shoulder injuries. In high-grade injuries, surgery is favored to ensure a correct restoration of the joint, especially in young athletes. The aim of this study was to compare the clinical, radiological and sport related outcomes of the arthroscopic stabilization with the fixation of the AC joint in a mini-open approach.

MATERIALS AND METHODS

19 patients treated arthroscopically (ASK) and 26 patients with an acute AC-joint dislocation Rockwood V who had undergone the mini-open (MO) surgery were included. Constant Murley Score (CMS), Taft Score (TS) and the Simple Shoulder Tests (SST) were evaluated. The sports activity level was determined according to Valderrabano and the athlete's recovery of their athletic activity level after surgery according to Rhee. Furthermore, all available X-ray images were analyzed.

RESULTS

Patients in the ASK group achieved an average score of 11.7 ± 0.6 points in the SST, 10.3 ± 1.8 points in the TS and 91.2 ± 11.8 points in the CMS. On average, patients in the MO group achieved results of 10.5 ± 1.4 points in the SST, 11.7 ± 0.7 points in the TS and 91.6 ± 9.8 points in the CMS. The ASK group showed significant difference regarding the CC distance in side comparison (Δ = 3.6 mm), whereas no significant difference was found in the MO group (Δ = 0.8 mm). In comparison of both groups, the posterior as well as the combined translation were significantly greater in the ASK group than in the MO group (posterior: ASK: 24.8 mm, MO: 19.3 mm, combined: ASK: 29.1 mm, MO: 20.9 mm). Residual horizontal instability was greater in the ASK group (43%) than in the MO group (32%). Similar results were achieved in sports activity and the recovery of athletic activity (Valderrabano: ASK: 2.8, MO: 2.6; Rhee: ASK: 1.6, MO: 1.5).

CONCLUSIONS

Both techniques prove to be effective for the stabilization of high-grade AC-joint disruptions in athletes and showed excellent clinical results. From a radiographic standpoint, the mini-open procedure appears superior to the arthroscopic technique. After mini-open surgery postoperative loss of correction is less common and greater horizontal stability is achieved. The results also suggest the mini-open technique is superior to the arthroscopic procedure when aiming to restore the athlete's original level of sports activity.

LEVEL OF EVIDENCE: 1

Surgical management of acute, high-grade acromioclavicular joint separations: a systematic review

Background

While a number of treatment options exist for repair of acute, high-grade acromioclavicular joint (ACJ) separation, none have emerged as the standard of care. The purpose of this study was to systematically review the literature on surgical treatment of acute, high-grade (Rockwood grades III-V) ACJ separations in order to compare outcomes between direct fixation and tendon graft ligament reconstruction.

Methods

A systematic review of the literature evaluating outcomes for acute ACJ separation treatment with direct fixation or free biologic tendon graft reconstruction was performed. The following databases were examined: the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2021), and Embase (1980-2021). Studies were included if they reported a mean time to surgery as <6 weeks, contained >10 patients with a minimum 1-year follow-up, and reported clinical or radiographic outcomes.

Results

A total of 52 studies met the inclusion criteria. Seven studies reported outcomes following tendon graft ligament reconstruction (n = 128 patients). There were multiple methods of direct fixation. Thirty-three studies utilized suture button constructs (n = 1138), 16 studies used hook plates (n = 567), 2 studies used coracoclavicular screws (n = 94), 2 studies used suture fixation (n = 93), 2 studies used suture anchor (n = 55), 2 studies used suture cerclage fixation (n = 87), 1 used single multistrand titanium cable (n = 24), and 1 used K wire (n = 11). The mean follow-up Constant scores ranged from 77.5 to 97.1 in the fixation group compared to 90.3-96.6 in the tendon graft group. The mean visual analog scale scores ranged from 0 to 4.5 in the fixation group and 0.1-1 in the tendon graft group. Net CC distance ranged from 17.5 to 3.6 mm in the fixation group and 7.4-4 mm in the tendon graft group. The revision rates ranged from 0.0% to 18.18% in the direct fixation group and 5.88%-17% in the tendon graft group.

Conclusion

Direct fixation and tendon graft reconstruction for management of acute, high-grade ACJ separations have similar patient subjective and radiographic outcomes, as well as complication and revision rates at a minimum 1-year follow-up.

[Injuries of the shoulder in winter sports]

Skiing as a sport has come a long way from the first competitive event in Norway in 1767 to about 200 million skiers today worldwide. With Germany alone recording around 8000 injuries annually, there is an increased need for awareness for winter-sport-related injuries and their management. According to the latest report by "Auswertungsstelle für Skiunfälle" (ASU, evaluation center for ski accidents), shoulder injuries alone account for more than 20% of injuries to all body regions (men 26.1% and women 13%). The most common injuries affecting the shoulder girdle are rotator cuff strains, glenohumeral dislocations, acromioclavicular dislocations and clavicle fractures. These injuries are primarily the result of four mechanisms: direct impact, axial load on an extended arm, resisted forced abduction of the arm, and external rotation forces resulting from a firmly planted ski pole in the grasp of a skier during a fall. In this article, we describe the three most common shoulder girdle injuries in winter sports along with their management and answer the most important questions for the athlete.

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.

Return to Play After Surgical Treatment of High-Grade Acromioclavicular Joint Injuries in the Australian Football League

Background:

Acromioclavicular joint (ACJ) injuries are the second most common upper limb injuries in the Australian Football League (AFL); however, there is little evidence on the return-to-sport results after surgical stabilization of the ACJ in this sporting population.

Purpose:

To investigate the return-to-sport time, on-field performance, and patient-reported outcomes in a series of professional AFL players after undergoing ACJ stabilization.

Study Design:

Case series; Level of evidence, 4.

Methods:

We conducted a retrospective case series of all AFL players who had undergone open twin-tailed dog-bone ACJ stabilization by a single surgeon between September 2013 and April 2017. Outcome measures included time to return to sport, on-field performance indicators (handballs, tackles, kicks, and AFL Fantasy and Supercoach scores), the Nottingham Clavicle Score, Oxford Shoulder Score, and the Specific Acromioclavicular Score. Patient-reported outcomes were evaluated at a minimum follow-up of 12 months.

Results:

Of 13 senior listed AFL players who underwent twin-tailed dog-bone surgery, 9 players were included. Mean follow-up was 24.8 months (range, 5-41 months) postoperatively. Mean return-to-sport time was 8.6 weeks for injuries that occurred within the season. The number of kicks, marks, handballs, and tackles as well as AFL Supercoach and Fantasy scores did not significantly change after surgery ( P > .05). Outcome measures showed a high level of patient satisfaction after surgery, with a mean Nottingham Clavicle Score of 92.2, Oxford Shoulder Score of 47.7, and the Specific Acromioclavicular Score of 7.5.

Conclusion:

In a collective of professional AFL players with ACJ injury, our twin-tailed dog-bone technique revealed return to competitive play could be achieved at a mean of 8.6 weeks without compromising on-field performance or patient-reported pain, function, and satisfaction.

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up

PURPOSE

To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.

METHODS

A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated.

RESULTS

There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated.

CONCLUSIONS

AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction.

LEVEL OF EVIDENCE

IV (Case Series).

[Arthroscopically-assisted treatment of acute and chronic dislocations of the acromioclavicular joint : A prospective clinical trial]

BACKGROUND

Injuries of the acromioclavicular joint (ACJ) are frequent and often occur during sports. While arthroscopically-assisted stabilization of acute injuries of the ACJ is a well-established procedure, there is not much data available for arthroscopically-assisted stabilization of chronic injuries of the ACJ.

OBJECTIVES

This study assesses clinical and radiological results of arthroscopically-assisted stabilization of acute and chronic injuries of the ACJ.

MATERIALS AND METHODS

Thirty-six patients with acute and chronic injuries of the ACJ were assessed in a prospective clinical trial. Twenty-five patients with acute injuries (group A) and eleven patients with chronic injuries (group B) were included in this study. Patients of group A were operated using two suture-button systems, while patients of group B received one suture-button system and an autologous gracilis tendon graft.

RESULTS

In group A, the mean preoperative Constant score rated 38, and the ASES score rated 34. At follow-up the Constant score (92) and the ASES score (89) had improved. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (15.8 mm) in comparison to the contralateral shoulder (10.9 mm). In group B, the preoperative Constant score measured 57. It improved to 72 points at follow-up. The ASES score improved from 39 to 72 points in the same period. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (18.9 mm) in comparison to the contralateral shoulder (12.4 mm).

CONCLUSIONS

Stabilization of acute injuries of the ACJ with two suture-button systems is related to very good shoulder function after one year. The native coracoclavicular distance cannot be restored with this procedure. Stabilization of chronic injuries of the ACJ with a suture-button system and an autologous gracilis tendon graft is related to improved shoulder function after one year. However, shoulder function cannot be fully restored with the stabilization technique presented.

Coracoclavicular Space Widening on Radiographs After Arthroscopic Stabilization With Suspensory Fixation Does Not Affect Athletic Performance

Purpose

To evaluate the effect of the coracoclavicular distance widening in athletes after arthroscopic acromioclavicular (AC) stabilization using a suspensory button fixation device in terms of function, athletic performance, or isokinetic assessment.

Methods

Sixty-eight athletes with a minimum 6-month follow-up after AC stabilization using suspensory button fixation were allocated in 2 groups, the widening group and non-widening group, according to the measured coracoclavicular distance after 6 months from the operation. The assessment was done every 6 months by Subjective Patient Outcome for Return to Sports (SPORTS) score, Athletic Shoulder Outcome Scoring System (ASOSS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, Constant-Murley score (CMS), and the coracoclavicular distance. Isokinetic testing was performed at 24 months postoperatively to evaluate shoulder abduction and external rotation strength.

Results

No statistically significant differences were found between the 2 groups in terms of the DASH, ASOSS, SPORTS, and the CMS, in addition to the isokinetic testing (P > .05). A statistically significant improvement in both groups over the follow-up stage was identified in the DASH, ASOSS, SPORTS, and the CMS (P < .05).

Conclusions

Coracoclavicular distance widening following arthroscopic suspensory button fixation for AC joint dislocation did not affect function, athletic performance, or isokinetic evaluation in athletes.

Level of Evidence

III; nonrandomized, comparative trial.

MRI in acute simple elbow dislocations: correlation of preoperative imaging and intraoperative findings of collateral ligaments and associated soft tissue injuries

PURPOSE

The aim of our study was the evaluation of correspondence among collateral ligaments and other soft tissue injuries detected by MRI and by intraoperative findings in a consecutive series of patients treated for simple elbow dislocation.

METHODS

After clinical and MRI examination, 16 out of 59 consecutive patients with moderate or severe instability after simple elbow dislocation were addressed to surgical treatment. There were 14 men and 2 women. The mean age was 39.6 years (range 16-69 years).

RESULTS

MRI showed full-thickness lesion of MCL in 9/16 patients (53.3%) and partial lesion in 6/16 patients (40%), and in 1 case, the MCL was considered intact. On the lateral side, MRI showed complete injury of LCL in 7/16 patients (46.6%) and partial injury in 7/16 patients (40%). No lesions of LCL were observed in 2 patients (13.4%). MCL was surgically explored in all the patients. We observed 10/16 full-thickness lesions (62.5%) and 6/16 partial lesions (37.5%). LCL was surgically explored in 11/16 patients. We observed 6/11 full-thickness lesions (54.6%) and 5/11 partial lesions (45.4%). In 3 cases, associated soft tissue injuries were detected. The rate of concordance between MRI and surgical findings was 87.5% (14/16 cases) on the medial side and 90.9% (10/11 cases) on the lateral side.

CONCLUSION

Our study demonstrated that MRI is a reliable and useful tool to investigate collateral ligaments and soft tissue injuries around the elbow and to plan the most adequate surgical treatment.

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

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

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

PURPOSE OF THE REVIEW

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

RECENT FINDINGS

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

Return to work after acromioclavicular joint stabilization: a retrospective case control study

BACKGROUND

Considering the epidemiology of acromioclavicular (AC) dislocation related to young and active patients, the impact on working capacity is highly relevant. The purpose of this study was to determine the capacity of work and time to return to work (RTW) after AC joint stabilization. We hypothesized that manual working patients show more restrictions returning to work.

METHODS

In this retrospective case series, pre- and posttraumatic working capacity of 54 patients (FU-rate 80.1%, FU time 23, range 18-45 month) stabilized in single TightRope technique was analyzed. Clinical outcome (DASH, Constant-Murley score) and complications were evaluated in addition.

RESULTS

Fifty one of 54 patients (94.5%) were returned to work at final follow-up. The median time to return was 13 (5-143) weeks. Manual working patients showed lower RTW-rates (91.2% vs. 100%; p = .151), longer RTW-time (15.5 vs. 6 weeks; p = .008), and more often persistent shoulder symptoms at work (55.9% vs. 5%; p < .001).

CONCLUSION

After stabilization of AC joint dislocation, the majority of patients returned to work, needing substantial time to return. Manual working patients required more time and often suffer under persistent symptoms at work.

Return to sport after surgical treatment for high-grade (Rockwood III-VI) acromioclavicular dislocation

PURPOSE

Acromioclavicular (AC) joint dislocations are common in a young and active population, especially in people performing contact sports. Full recovery with a fast and high rate of return to sport is desirable. This systematic review aims to combine patient outcomes in order to help surgeons in addressing patient expectations regarding the return to sport after surgical intervention for AC dislocations.

METHODS

To conduct this systematic review, the PRISMA guidelines were followed. Articles were included if written in English or Dutch and evaluated return to sport after any type of surgical intervention for Rockwood types III to VI AC dislocations in patients practicing sports. Outcome parameters were return to sport, time to return to sport, level of sport, functional outcome scores and complications.

RESULTS

Twelve studies involving 498 patients were included, of which 462 patients practiced sports. 432 (94%) patients returned to sport. The weighted mean time to return to sport was 4.0 months. 338 out of 401 patients (84%) returned to the same level of pre-injury sport and 35 patients (9%) lowered their level of sport. The weighted mean Constant score was 92 out of 100.

CONCLUSION

The rate of return to sport after surgical intervention for Rockwood (RW) III-VI AC dislocations is high. However, the level of evidence was low and due to the methodological heterogeneity between studies, subgroup analyses of return to sport outcomes were not feasible.

LEVEL OF EVIDENCE

Systematic review of level I-IV studies, level IV.

Current concepts in management of ACJ injuries

Acromioclavicular joint injury is common in young individuals who suffer direct trauma to the shoulder. Treatment of acromioclavicular dislocation is controversial with regards to the indication of operative management, timing of surgery, whether to perform open or arthroscopic surgery, method of stabilisation (rigid or non-rigid) and type of graft used for repair or reconstruction. Current evidence supports conservative management for Rockwood types I and II, while types IV, V and VI benefit from surgery. The optimal management of type III injuries in high demand patients remains contentious. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Few studies with a low level of evidence suggest arthroscopic techniques and anatomical ligament reconstruction have better outcomes when compared to older techniques of rigid coracoclavicular fixation. The aim of this article is to look at the current evidence and address these controversial issues.

Return to Sport and Clinical Outcomes After Surgical Management of Acromioclavicular Joint Dislocation: A Systematic Review

PURPOSE

To evaluate the rate at which athletes return to sport after surgical management of acute and chronic acromioclavicular (AC) joint dislocations.

METHODS

Three databases-PubMed, MEDLINE, and EMBASE-were searched from database inception until October 28, 2017, by 2 reviewers independently and in duplicate. The inclusion criteria were English language studies that reported return to sport outcomes in patients undergoing surgical management of AC joint dislocations.

RESULTS

Overall, 12 studies with a combined total of 315 patients met the inclusion criteria, with a mean age of 33.8 years (range, 18-65 years) and a mean follow-up of 34.9 months (range, 6-126 months). Of the 12 included studies, 1 was a prospective comparative study (Level II), 1 was a retrospective comparative study (Level III), 1 was a prospective case series (Level IV), and 9 were retrospective case series (Level IV). The rates of return to any level of sport ranged from 94% to 100% (I² = 0%), whereas the rates of return to the preinjury level of sport ranged from 62% to 100% (I² = 61%). The pooled rate of return to preinjury level of sport in type V AC joint separations was 86.2% (95% confidence interval = 68.1%-98.0%), whereas that after type III or IV AC joint injuries was 89.6% (95% confidence interval = 79.9%-96.9%).

CONCLUSIONS

An almost perfect rate of return to sport participation after surgical management of AC joint dislocations have been reported, with most returning to their preinjury level of sport. The rates of return to sport were comparable across the different types of injuries and surgical procedures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV investigations.

Editorial Commentary: Return to Sport After Surgical Treatments of the Acromioclavicular Joint Dislocation Seems to Be Almost Perfect in the Literature

Systematic reviews identify completed studies that address a research question and evaluate the results of these studies to arrive at conclusions about a body of research. They should be encouraged because the findings, with power enhanced by the larger sample size available from the combined studies, often represent an important scientific contribution. The systematic review findings also can be a useful background for developing practice guidelines in the future. One of limitations of this approach is a risk of publication bias. Studies with negative results are more likely to remain unpublished or excluded from the review owing to a lack of reporting outcome of the specific interest. Although publication bias is difficult to eliminate, it should be addressed by the authors with appropriate statistical procedures that may be helpful in detecting its presence. Negative results should not be masked by overall good outcomes. This rather long caveat relates to a recent review showing that return to sport after surgical treatments of acromioclavicular joint dislocation seems to be almost perfect in the literature. Perfection is rare, so publication bias could be a limitation of the review.

Functional Outcome of Modified Weaver Dunn Technique for Acromioclavicular Joint Dislocation

BACKGROUND

The debate about the ideal surgical procedure for acromioclavicular joint (ACJ) dislocation is still unresolved and newer techniques are being evolved continuously. The present study evaluates functional outcome of ACJ reconstruction using the modified Weaver Dunn procedure.

MATERIALS AND METHODS

35 patients (26 males, 9 females) with ACJ dislocation, between the age group of 18-48 years (mean age 31 years), were operated using modified Weaver Dunn procedure at our center from May 2005 to June 2010. The dominant side was involved in 25 patients (22 right, 13 left). The mean period from the time of injury to the surgery was 14 days (range 4-26 days). All the patients were assessed with Oxford shoulder score and the time required to return to preinjury level was recorded.

RESULTS

At the mean followup of 95 months (range 72-120 months), the mean Oxford Shoulder Score improved from 25 ± 7.2 to 43 ± 6.9. 85% (30 out of 35) patients had satisfactory results, while 15% (5 out of 35) had mild shoulder dysfunction using this scoring system. Five patients had radiological evidence of Grade 2 ACJ subluxation. Out of these five patients, two developed ossification around the coracoclavicular ligament. Three patients had intermittent mild pain without any functional disability, and one had a moderate restriction of shoulder movements.

CONCLUSION

ACJ reconstruction, using the modified Weaver Dunn procedure in ACJ dislocation, is a reproducible procedure and provides a good functional outcome.

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.

Modified closed-loop double-endobutton technique for repair of rockwood type III acromioclavicular dislocation

Acromioclavicular dislocation (ACD) is a common injury. According to the Rockwood classification, ACD is classified into six types (type I–VI); however, for type III injuries, it remains controversial whether or not operative treatment should be applied. Numerous studies have advocated early surgical treatment to ensure early rehabilitation activities. Thus, the present study aimed to investigate a modified closed-loop double-endobutton technique (MCDT), that may be used to repair Rockwood type III ACD. In the current study, 61 patients with Rockwood type III ACD were enrolled during a period of 5 years at the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University. Patients were divided into three groups according to the surgical method used, the MCDT group (n=20), the common closed-loop double-endobutton technique (CCDT) group (n=21), and the clavicular hook plate fixation (CHPF) group (n=20). Preoperative and intraoperative information were recorded. Furthermore, the functional scores of injured shoulder were evaluated prior to surgery and following surgery with a 1-year follow-up. Among the three groups, postoperative functional scores were significantly more improved compared with those prior to surgery (P<0.05), and no significant difference was observed regarding the coracoclavicular interval with the 1-year follow-up (P>0.05). Postoperative functional scores in the MCDT and CCDT groups were significantly more improved compared those in the CHPF group (P<0.05). In addition, the duration of surgery in the MCDT group was significantly shorter compared with that in the CCDT group (P<0.05). Furthermore, compared with the CHPF group, the incision length was significantly shorter with reduced hemorrhage in the MCDT group (P<0.05). In conclusion, the results of the current study suggest that MCDT is more simple, convenient and efficient compared with CCDT, and is worth popularizing.