Surgical reconstruction of the acromioclavicular joint: Can we identify the optimal approach?

Fixation failure and early loss of reduction with the use of suture anchors for surgical repair of acromioclavicular joint dislocation: a case series

Background

Suture anchors have been used in surgical repair of acromioclavicular joint (ACJ) dislocation. While some reports indicate favorable results, others emphasize less promising outcomes. This case series reports our experience with suture anchors for surgical treatment of ACJ dislocation.

Methods

Clinical and radiographic outcomes in three patients treated operatively for ACJ dislocations were reviewed. In all patients, two suture anchors were inserted in the coracoid (unicortical) and #5 nonabsorbable suture from the suture anchor was shuttled through drill holes in the clavicle and tied over two button devices. The coracoclavicular ligaments were reconstructed using a figure of eight semitendinosus allograft around the coracoid and clavicle. Postoperatively, sling immobilization was used for 6 weeks, and physical therapy was initiated at 6 weeks with contact activity allowed at 6 months.

Results

Three male patients underwent treatment for Rockwood type 3 (chronic; n = 1) and type 5 (n = 2) ACJ dislocations. Loss of reduction was noted within 6 weeks postoperatively. Two patients exhibited failure due to complete suture anchor pullout and the third patient had partial pull out of one of the anchors. Additionally, the third patient also suffered a coracoid fracture adjacent to the anchor's placement after sustaining direct trauma to his shoulder, one-year postoperatively.

Conclusion

In our case series, we found a high rate of fixation failure and early loss of reduction with the use of suture anchors for the treatment of ACJ dislocation. These findings should be taken into consideration when selecting an appropriate implant for fixation of ACJ dislocation.

Tendon graft through the coracoid tunnel versus under the coracoid for coracoclavicular/acromioclavicular reconstruction shows no difference in radiographic or patient-reported outcomes

INTRODUCTION

The purpose of this prospective study was to report the outcomes of two different methods in CC and AC reconstruction for the treatment of AC separation using a tendon graft and knot-hiding titanium clavicular implant.

MATERIALS AND METHODS

Twenty-seven patients with Rockwood grade III and V acromioclavicular (AC) separations were randomized into two groups. The primary outcome was whether taking the tendon graft through the coracoid risked a fracture. The following were secondary outcomes: follow-up of clavicular wound healing and Nottingham Clavicle score, Constant score, and Simple Shoulder Test results obtained preoperatively and 24 months postoperatively. The anteroposterior radiographic change between the clavicular and coracoid cortexes and the clavicular tunnel diameter was measured postoperatively and 24 months postoperatively. General patient satisfaction with the outcome (poor, fair, good, or excellent) was assessed 2 years postoperatively.

RESULTS

No coracoid fractures were detected. No issues in clavicular wound healing were detected. The mean Nottingham Clavicle score increased from a preoperative mean of 42.42 ± 13.42 to 95.31 ± 14.20 (P < 0.00). The Constant score increased from a preoperative mean of 50.81 ± 17.77 to 96.42 ± 11.51 (P < 0.001). The Simple Shoulder Test score increased from a preoperative mean of 7.50 ± 2.45 to 11.77 ± 1.18 (P < 0.001). The changes were significant. The coracoclavicular distance increased from 11.88 ± 4.00 to 14.19 ± 4.71 mm (P = 0.001), which was significant. The clavicular drill hole diameter increased from 5.5 to a mean of 8.00 ± 0.75 mm. General patient satisfaction was excellent.

CONCLUSIONS

There were no significant differences between the two groups. There were no implant related complications in the clavicular wound healing. The results support the notion that good results are achieved by reconstructing both the CC and AC ligaments with a tendon graft.

STUDY REGISTRATION

This clinical trial was registered on Clinicaltrials.gov.

Open Acromioclavicular Repair With a Suture Cerclage Tensioning System: A Case Series

Introduction Numerous surgical techniques to address a type III and type V acromioclavicular (AC) joint separation have been described in the literature, but a preferred standard approach is still in debate. Current approaches include anatomic reduction, coracoclavicular (CC) ligament reconstruction, and anatomic reconstruction of the joint. In this case series, subjects received a surgical approach that avoids metal anchors and utilizes a suture cerclage tensioning system to achieve adequate reduction. Surgical technique An AC joint repair was achieved with a suture cerclage tensioning system, which allows the surgeon to apply a specific amount of force on the clavicle to achieve adequate reduction. This technique repairs the AC and CC ligaments, restoring the anatomy of the AC joint while avoiding some of the common risks and disadvantages associated with metal anchors. Methods From June 2019 to August 2022, 16 patients underwent repair of the AC joint with a suture cerclage tension system. Inclusion criteria included the diagnosis of type III or type V AC joint separation with another concomitant injury, acute and chronic injury, and patients who attended all their postoperative visits. Exclusion criteria included patients who lost to follow-up or patients who missed any of their postoperative visits. Radiographic images were taken during each subject's preoperative and postoperative visits, and the CC distance was measured to determine the integrity of the all-suture cerclage repair. Results Of the 16 patients included in this case series, radiographic images taken during each subject's postoperative visit showed a stable construct with little changes in the CC distance. The average change in CC distance when comparing the two-week and one-month postoperative follow-up is 0.2mm. The average change in CC distance when comparing the two-week and two-month postoperative follow-up is 1.45mm. The average change in CC distance when comparing the two-week and four-month postoperative follow-up is 2.6mm. Conclusion Overall, an AC joint repair with the suture cerclage tension system can be a viable, cost-effective technique for restoring vertical and horizontal stability. Although follow-up, larger-scale studies are required to determine the biomechanical integrity of the construct with an all-suture approach, this case series presents 16 subjects whose postoperative radiographic images showed only a small change in CC distance at two to four months after surgery.

The correlation between acromial osteolysis and acromion types in the treatment of acromioclavicular joint dislocation with hook plate

This study aimed to radiologically evaluate the effect of hook plates used in the treatment of acromioclavicular joint (ACJ) dislocations on the development of subacromial osteolysis (SAO) according to acromion types. A total of 43 patients with mean age of 38.5 (19-77) years who were diagnosed with AC dislocation and applied neutral clavicular hook plate between 2013 and 2020 were retrospectively evaluated. Acromion types were determined by measuring acromion slope angle on lateral shoulder radiography and 3-dimensional (D)-CT of the patients. Presence of SAO was classified according to the severity of erosion in the subacromial region (grade I: minimal osteolysis, grade II: subacromial erosion <2 mm, grade III: subacromial erosion >2 mm, grade IV: cut-through of the acromion) on postoperative 3D - CT and correlation with acromion types was analyzed. Incidence of SAO was significantly higher among type 1 acromion compared to type 2 and type 3 acromion (P = .003). While osteolysis was observed in 21 patients, no osteolysis was observed in 22 patients. Osteolysis occurred in all patients with type 1 acromion, 7 patients with type 2 acromion, and 5 patients with type 3 acromion. Since the hook tip in the sagittal plane passes posterior to the center of the acromion and the concavity of the subacromial surface is inadequate in the type 1 acromion, we believe that the increased pressure applied by the hook tip on the subacromial cartilage increases the risk of SAO. We predict that the use of hook plates with an angle of 15-20 degrees, similar to the patient's AC angle, rather than neutral hook plate, will reduce the risk of osteolysis in patients with type 1 acromion.

Arthroscopic Coracoclavicular Reconstruction Combined with Open Acromioclavicular Reconstruction Using Knot Hiding Clavicular Implants Is a Stable Solution

Purpose

The purpose of this noninterventional, register-based study was to report the outcomes and wound healing of surgically treated chronic acromioclavicular (AC) dislocations using a tendon graft and knot-hiding titanium implants.

Methods

Thirty-two cases with chronic AC separation underwent an arthroscopic coracoclavicular (CC) ligament reconstruction and an open AC ligament reconstruction using knot-hiding titanium implants. The wound healing was assessed 2 months after the operation. The Nottingham Clavicle score, Constant score, and Simple Shoulder Test were obtained postoperatively and at a minimum of one-year postsurgery. The radiographic change in distance between the clavicular and coracoid cortices and clavicular tunnel diameter was measured. General patient satisfaction with the outcome (poor, fair, good, or excellent) was also assessed 1 year postoperatively.

Results

The mean Nottingham Clavicle score increased from a preoperative mean of 41.66 ± 9.86 to 96.831 ± 5.86 (P ≤ .05). The Constant score increased from a preoperative mean of 44.66 ± 12.54 to 93.59 ± 7.01 (P ≤ .05). The Simple Shoulder Test score increased from a preoperative mean of 7.00 ± 2.14 to 11.84 ± .63 (P ≤ .05). The coracoclavicular distance increased from 11.32 ± 3.71 to 13.48 ± 3.79 mm (P ≤ .05). The clavicular drill hole diameter increased from 6 mm to a mean of 6 to a mean of 8.13 ± 1.12 mm. Twenty-three (71.9%) patients reported an excellent outcome, and nine (28.1%) reported a good outcome. One clavicular fracture occurred but no coracoid fractures. There was one reconstruction failure leading to a reoperation.

Conclusions

In this series, combining the arthroscopic CC ligament reconstruction to an open reconstruction of the AC joint with a tendon graft proved to be a stable solution. The knot-hiding titanium implant effectively eliminated the problems related to the clavicular wound healing.

Level of Evidence

Level IV, therapeutic case series.

Anatomic reconstruction of the acromioclavicular joint provides the best functional outcomes in the treatment of chronic instability

PURPOSE

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

METHODS

Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of chronic 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

Fourty-four studies were included for a total of 1020 shoulders. Mean age of participants was 38 years. Mean follow-up was 32.9 months. Arthroscopic techniques showed better results than open approach (p < 0.0001). Synthetic reconstructions demonstrated better functional outcomes compared to internal fixation and biologic techniques (p < 0.0001). Among biologic techniques, combined coracoclavicular and acromioclavicular ligaments reconstruction showed better Constant (p = 0.0270) and ASES (p = 0.0113) scores compared to isolated coracoclavicular ligaments reconstruction; anatomic biologic non-augmented graft reconstruction showed better Constant (p < 0.0001), VAS (p < 0.0001) and SSV (p = 0.0177) results compared to augmented techniques. No differences in functional outcomes could be found between anatomic biologic non-augmented graft versus synthetic reconstructions. Overall, methodological quality of the included studies was low.

CONCLUSION

Anatomic reconstructions, both synthetic and biologic, showed the best functional results.

LEVEL OF EVIDENCE

IV.

Anatomy and Correlation of the Coracoid Process and Coracoclavicular Ligament Based on Three-Dimensional Computed Tomography Reconstruction and Magnetic Resonance Imaging

Background

The anatomy of the coracoid process and coracoclavicular (CC) ligament have been described and the correlation between them has been assessed based on 3-dimensional computed tomography (CT) reconstruction and magnetic resonance imaging (MRI), which provide a guide for coracoclavicular ligament reconstruction.

Material/Methods

Data were collected from 300 patients who underwent both CT and MRI of the shoulder joint from January 2017 to January 2019 at the Jiang’an Hospital of Traditional Chinese Medicine. The coracoid process was observed and classified and parameters of the CC ligament were measured according to different corneal types. All of the statistics were collected and classified by 2 radiologists, and average values were determined.

Measurements of segments were taken as follows: ab – In the coronal plane, the length of the CC ligament from the central point of the CC ligament at the clavicular attachment to the CC ligament at the center of the CC attachment); ac – The distance from the center point of the CC ligament at the supraclavicular attachment to the acromioclavicular joint; de – In the sagittal plane, the length of the CC ligament from the center of the clavicular attachment to the coracoid attachment point; fg – The maximum diameter of the CC ligament at the anterior and posterior margins of the clavicle attachment; hi – The largest diameter of the CC ligament at the anterior and posterior edge of the coracoid process attachment; dj – The distance of the coracoclavicular ligament from the center point of the coracoid process attachment to the coracoid process tip; kl – The distance in the supraclavicular plane from the coracoclavicular ligament to the subcoracoid process.

Results

The analysis showed that there are 5 types of coracoid process: gourd (31%), short rod (20%), long rod (22.3%), wedge (10.3%), and water drop (6.3%). There were statistically significant differences between the lengths of the ac and hi segments in the among the wedge and gourd-type and the short rod and water drop-type coracoid processes. There were statistically significant differences between the lengths of the ab, de, and fg segments in the short rod, gourd, and long rod-type coracoid processes. There were statistically significant differences between the lengths of the ac, fg, hi, dj, and kl segments in the water drop, gourd, and long rod-type coracoid processes.

Conclusions

The present study indicated that measurement of the CC ligament and the different shapes of the coracoid process provide an anatomical basis for the diagnosis and treatment of shoulder diseases and the data can be used to improve the safety of CC ligament reconstruction.

Arthroscopy-Assisted Reconstruction of the Coracoclavicular and Acromioclavicular Ligaments Using a Tendon Graft and Knot-Hiding Clavicular Implants in Chronic Acromioclavicular Separations

The purpose of this study is to introduce an arthroscopy-assisted technique to treat chronic acromioclavicular (AC) dislocation. The method involves reconstructing both the coracoclavicular (CC) and AC ligaments in a practical and reliable way using a semi-tendon graft and knot-hiding implants. In the CC reconstruction, the anterior graft limb replaces the trapezoid ligament, whereas the dorsal limb is wrapped around the dorsal edge of the clavicle to reconstruct the conoid ligament. One 5.5-mm drill hole is needed in the clavicle since the semitendinosus graft and the interconnecting supportive suture share the same drill hole. A 2.4-mm drill hole through the coracoid is needed for the interconnective suture. The technique uses knot-hiding titanium implants that are designed to be used with a tendon graft. After finishing the arthroscopic CC reconstruction, the dorsal end of the tendon graft is openly taken over the AC joint to openly reconstruct the superior AC ligament. The AC capsule is then plicated over the reconstruction. The arthroscopic part of the reconstruction is not technically difficult for an experienced arthroscopic shoulder surgeon. For success, it is essential to achieve a tension-free reduction of the distal clavicle and to provide sufficient recovery time postoperatively.

Arthroscopic-Assisted Acromioclavicular Joint Dislocation Repair: A Modified Technique for Horizontal Stabilization Using Suture Anchors

Acromioclavicular (AC) dislocation is a common lesion often resulting from a sports injury. Nowadays, treatment is still controversial mainly in grade III lesions according to the Rockwood classification. For most surgically treated AC acute dislocations, treatment is performed with an arthroscopic procedure that anatomically reconstructs the coracoclavicular ligaments. Increasing knowledge about AC joint biomechanics has underlined the importance of its horizontal stability through the superior and inferior AC ligaments. Moreover, the pattern of lesion tends to repeat itself, with the superior AC ligament being torn most frequently from the clavicular side in a peeling fashion. Therefore, the purpose of this note is to describe the technical aspects of additional horizontal stability through superior AC ligament repair using suture anchors.

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

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