Acromioclavicular joint dislocations

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).

Management of type III acromioclavicular joint dislocation: A Delphi consensus survey by Shoulder & Elbow Society, India (SESI)

PURPOSE

The study aimed to report the results of the Delphi survey conducted by the Shoulder, Elbow Society India (SESI), to achieve consensus on ambiguous topics in managing type III acromioclavicular joint (ACJ) dislocations.

METHODS

This study was based on responses from the Shoulder Elbow Society India (SESI) panel of peer-selected twenty senior surgeons practicing shoulder orthopedics. They participated in two rounds of the survey to obtain consensus on several topics pertaining to the management of type III ACJ dislocations. Consensus was achieved when at least 70 % of the panel members selected at least a 4-point on a 5-point Likert scale.

RESULTS

Our Delphi survey reached a consensus on seven topics of ambiguity. An anteroposterior and axillary view of the shoulder without any traction or weight in hand is sufficient in the setting of a suspected type III ACJ dislocation. Magnetic resonance imaging (MRI) is not routinely indicated in type III ACJ dislocation. Either cross-arm adduction X-rays or clinical examination may be used to distinguish between ISAKOS (International Society of Arthroscopy, Knee surgery and Orthopaedics Sports medicine) IIIA and B classification of ACJ to identify stable and unstable injuries. Conservative treatment can be offered to patients who have stable injuries and who are not high-demand individuals in acute type III ACJ dislocations. In conservative management of type III ACJ dislocation, a two-week sling suffices. Jones strapping has no clear advantage over a shoulder sling. Coracoclavicular reconstruction with an autograft is an acceptable way to treat symptomatic, chronic grade III ACJ dislocation.

CONCLUSION

The survey helped achieve consensus on several controversial issues related to type III ACJ dislocations. However, there remains ambiguity on the definition of chronicity of such dislocations, the necessity of bilateral Zanca views, and the duration of conservative trial before switching to a surgical line of management.

Innovative approach to managing acromion fracture and acromioclavicular joint dislocation: A case report

INTRODUCTION

This study delves into the management of acromion fractures and acromioclavicular (AC) joint dislocations-orthopedic injuries with significant implications for shoulder function. Despite their infrequency, these injuries present challenges due to potential persistent pain and functional limitations. Current treatment strategies span from conservative measures to surgical interventions, yet there exists a notable gap in comprehensive data on specific surgical approaches.

PRESENTATION OF CASE

We present a compelling case involving a 38-year-old male athlete who sought medical attention following a motor vehicle accident due to severe right shoulder pain. Upon admission to the emergency ward, the patient reported an inability to move the affected shoulder. Radiographic evaluations, comprising X-ray and computerized tomography scans, revealed a displaced fracture at the base of the acromion coupled with an AC dislocation. A novel surgical technique was employed, featuring coracoid fixation with mersilene thread and a 2-hole reconstruction plate-a distinctive approach in the field.

DISCUSSION

The systematic rehabilitation plan yielded successful healing and the restoration of normal shoulder function, offering promising insights into potential advancements in orthopedic practices.

CONCLUSION

This case contributes valuable knowledge to the understanding of these complex injuries, paving the way for further exploration and refinement in their management. The innovative surgical approach showcased underscores the importance of continued research and exploration to enhance the overall treatment landscape for acromion fractures and AC joint dislocations.

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.

Can a coracoclavicular screw added to the clavicular hook plate reduce subacromial stress? A finite element analysis

OBJECTIVES

The aim of this study was to investigate the stresses on the plate and the clavicle in the standard clavicular hook plate model and the clavicular hook plate models with a coracoclavicular (CC) screw by finite element analysis (FEA).

MATERIALS AND METHODS

The FEA models were created with the combination of acromion, clavicle, coracoid process, 8-hole clavicular hook plate and screw components. Model 1 was created as a standard clavicular hook plate model and plates were implanted to the clavicle and the acromion by six locking screws. Model 2 was created by a cortical screw placed in the coracoid process through the third hole of the plate (CC screw) and fixation of hook plate by five locking screws. The upward-pull force was applied to clavicle at the insertion of sternocleidomastoid muscle with three axes. The stress exerted by acromion on the hook of the plate, stresses on the plate, clavicle, and CC screw were analyzed.

RESULTS

When the screw holes were compared, in Model 1, the highest stress was found in the last hole of the plate. In Model 2, the highest stress was detected on the CC screw. The stress on the clavicle was found to be 0.14 Mpa in Model 1 and 0.21 Mpa in Model 2. In Model 1 and Model 2, the stress exerted by acromion on the subacromial part of the plate was found to be 2.05 KPa and 1.66x10-6 KPa, respectively.

CONCLUSION

The results of this study show that addition of CC screw to the standard clavicular hook plate shares the loading and reduces the stress on the hook of the plate.

An Accuracy Comparison of Minimally Invasive Transclavicular-Transcortical Drilling with Free-Hand, C-Shape and Assembly-Type Guide Device: An In Vitro Study

OBJECTIVES

Ensuring the accuracy of transclavicular-transcoracoid drilling in the anatomical reconstruction of the coracoclavicular ligament complex with minimally invasive incisions remains a major problem for inexperienced surgeons. The purpose of this study was to design an assembly guide device for transclavicular-transcoracoid drilling with minimally invasive incisions, to manufacture the finished product, and to compare its feasibility and accuracy with the existing C-shape guide devices and free-hand techniques.

METHODS

An assembly-type guide device was designed and produced using computer-aided design and three-dimensional printing. The specimen data of 54 human shoulders from 27 gross specimen (14 males and 13 females) treated by free-hand drilling, C-shape device drilling, and assembly-type guide device drilling from October 2018 to January 2021 were analyzed in a controlled laboratory study. Fifty-four human shoulder specimens were randomly assigned into free-hand (n = 18), C-shape (n = 18), and assembly (n = 18) groups by drawing lots for transclavicular-transcoracoid drilling by three inexperienced surgeons. After the drilling procedure was completed and the devices were removed, the operation outcomes were assessed and evaluated. Distances from the tunnel edge to the coracoid's medial (d_m ) and lateral (d_l ) edges, operation time, and tunnel location zones on the coracoid's inferior surface of all specimens in the three groups were measured to evaluate the surgical accuracy and efficiency.

RESULTS

All specimens in the three groups completed the drilling operation successfully and were correctly measured. The distance differences (d_d ) between d_m and d_l in the free-hand, C-shape, and assembly groups were 3.2 ± 1.8 mm, 1.8 ± 1.0 mm, 1.0 ± 0.8 mm, respectively. The d_d of the free-hand group was higher than that of the other two groups (p < 0.001). The tunnel exit points on the inferior coracoid surface located in undesired zones were six (33%), one (6%), and zero in the free-hand group, C-shape group, and assembly-type group, respectively (p = 0.012). The operation time in the free-hand, C-shape, and assembly groups were 198 ± 36 s, 256 ± 64 s, and 353 ± 88 s, respectively. The operation time of each group significantly differed from that of the others (p < 0.001).

CONCLUSION

The assembly-type devices may be the first choice for inexperienced surgeons while both the C shape devices and assembly-type guide devices achieved higher accuracy than free-hand techniques.

Comparison of hook plate versus T-plate in the treatment of Neer type II distal clavicle fractures: a prospective matched comparative cohort study

Background

This study aimed to compare the clinical and radiological outcomes of distal clavicle fracture fixation with a hook plate versus the standard non-locking T-plate for unstable Neer type II fractures.

Methods

A prospective matched cohort study including two groups of hook plates and T-plates fixation was conducted in our two tertiary trauma centers. Patients with distal clavicle fractures Neer type II were assessed for union and the Constant-Murley score (CMS) at 1-, 3-, and 6-month follow-ups. Inadequate radiographic consolidation > 6 months after surgery was defined as non-union. Subscales of CMS_pain, CMS_{activities of daily living}, CMS_{range of motion (ROM)}, and CMS_strength were also compared between groups. According to recommendations, the implant was removed after union confirmation in the hook plate at a planned second surgery.

Results

Sixty consecutive patients were enrolled: 30 in the T-plate group and 30 in the hook plate group. CMS showed similar functional outcomes for T-plates and hook plates at all follow-ups (Month 6: 92.0 vs. 91.7, P = 0.45). However, on the month 1 follow-up, the T-plate group scored higher than the hook plate group for ROM and pain (CMS_pain = 13.0 vs. 12.3, P = 0.03; CMS_ROM = 35.2 vs. 33.2, P = 0.002). Despite this, Pain, ROM, and other CMS domains were comparable between groups (P > 0.05). The mean time to union was 2.5 + 1.4 months for the T-plate group and 2.3 + 1.6 months for the hook plate group (P = 0.44). There was one fixation failure in each group and one periprosthetic fracture in the hook plate group (two revisions for the hook plates and one for T-plates, P = 1.00). Non-union and other complications were not observed.

Conclusion

Both surgical approaches resulted in full recovery and good function. However, in the hook plate group ROM and pain scores were lower at 1 month. Standard non-locking T-plates are a viable alternative to hook plates with low cost and promising outcomes for treating displaced distal clavicle fractures.

Anchorless Acromioclavicular and Coracoclavicular Ligament Repair Using a Graft-Passing Instrument to Pass Suture Under the Coracoid

Acromioclavicular joint separation is a common shoulder injury. Grade I and II separation may be treated nonoperatively, whereas higher grades tend to require surgical intervention. Various repair techniques have been described in the literature, with no consensus on the gold standard. This Technical Note describes our use of a graft-passing instrument to pass suture under the coracoid during an anatomic reconstruction of both the acromioclavicular and coracoclavicular ligaments. Although this approach is technically challenging, it avoids coracoid drilling and requires smaller-diameter clavicle and acromion drilling. Furthermore, using suture instead of graft material increases the cost-effectiveness of the procedure.

Operative treatment of acute acromioclavicular joint dislocations graded Rockwood III-V: a retrospective and comparative study between three different surgical techniques

BACKGROUND

the optimal treatment of acute type III-V acromioclavicular (A-C) Rockwood dislocations is still a matter of discussion in orthopaedic surgery.

AIM OF THE WORK

retrospective and comparative evaluation of the clinical and radiographic results of three different surgical techniques for stabilization of A-C joint using tension band wiring, hook plate and TightRope.

METHODS

a consecutive series of patients, treated from January 2014 and November 2019, were divided into three groups according to the surgical method used. They were clinically and radiographically assessed and the results were compared with those present in the literature.

RESULTS

66 patients, with a mean age of 44.7 years, were enrolled with a mean follow-up of 37.7 months (range 6-58 months). All patients, regardless of the group, had satisfactory outcome. According to the DASH score, statistically significant difference favours the TightRope Group (TRG) fixation (p<0.005). The TRG showed the highest mean Constant score (96,1); there are no significative differences between the clinical scores of Hook Plate Group (HPG) and Tension Band Wiring Group (TBWG). However, these two methods showed numerous complications, especially metal-work mobilization and stiffness respectively.

CONCLUSIONS

good results can be overall achieved with primary fixation by the three different surgical methods under investigation. The TightRope system exhibited some advantages such as higher clinical scores, early recovery of range of  movements, longitudinal surgical incision with non-keloid scar, no need for a second surgery and lower rate of complications.

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.

Midterm Results of Tension Band Wiring Technique for Acute Rockwood Type III Acromioclavicular Joint Dislocation

Background The aim of this study was to evaluate the clinical and radiological results of patients with acute type III Rockwood acromioclavicular joint (ACJ) dislocation treated surgically by employing tension band wiring. Methods The study included 24 patients with traumatic type III ACJ dislocations according to the Rockwood classification. The clinical and radiological outcomes of patients were assessed at the final follow-up visit. Implant failure and reduction loss were assessed using radiographs, whereas the Constant-Murley scoring system was used to assess the patients clinically. Results The mean follow-up period was 3.5 ± 1.3 years (range: 1-6 years). The mean age of the patients was 41.8 ± 11.7 years (range: 19-64 years) and the mean length of hospital stay was 2.3 days (range: 1-6 days). The fixation material was removed postoperatively at an average of 7.2 ± 9.9 months (range: 3-40 months). At the end of the follow-up period, the mean Constant-Murley score was 72.5 ± 12.8 (range: 50-90). The ACJ reduction was stable in 13 (54.2%) patients. Residual subluxation was detected in 11 (45.8%) patients. Distal clavicular osteolysis was noted in six (25%) patients. Acromioclavicular osteoarthritis was detected in five (20.8%) operated shoulders on follow-up radiographs. During the follow-up, Kirschner-wire migration and breakage occurred in four (16.6%) and seven (29.1%) patients, respectively. Conclusions This study showed that surgical treatment with the tension band wiring method provided functionally satisfactory results even if complications developed because of the presence of implants. Independent of age, we can recommend it as the primary treatment method for patients who do not have very high expectations regarding their shoulder function. Additionally, we think that reducing the duration of implant retention will reduce the incidence of complications.

Comparison of the Results of Hook Plate and Endo-Button Used in the Surgical Treatment of Acromioclavicular Joint Separation

Purpose: Our study aimed to compare the clinical outcomes between endo-button and hook plate fixations for the treatment of acute unstable acromioclavicular (AC) joint dislocation.

Materials: A retrospective evaluation of patients with acute AC joint dislocation who were treated between February 2009 and December 2019 was performed. The study was conducted with 39 patients who met the inclusion criteria. Patients were divided into group 1, operated with a hook plate, and group 2, operated with an endo-button. The demographic features and postoperative complications were analyzed. The disability of arm, shoulder, and hand (DASH) scoring system, modified University of California at Los Angeles shoulder score (UCLA) scale, and the visual analog scale (VAS) scores were used to evaluate shoulder functions in these patients. Shoulder functions were evaluated one, three, six, and twelve months after surgery.

Results: There were 21 patients in group 1 and 18 patients in group 2. Gender distribution was 28 male and 11 female, and the average age was 30.9 years (18-50). There were no significant differences in age, sex, side of injury, or follow-up time from injury to surgery between the two groups. The UCLA scores of group 1 and group 2 one month after surgery were 17.2 and 27.2, respectively. DASH scores of group 1 and group 2 one month after surgery were 82 and 52, respectively. The VAS scores of group 1 and group 2 one month after surgery were 70 and 14, respectively. For all scores at first month post-surgery, there were statistically significant differences between groups, but scores became similar 12 months after surgery.

Conclusion: Postoperative shoulder scores of patients with endo-button showed superiority in the early stages. However, after a year of follow-up, the results of the surgery performed with an endo-button or a hook plate were similar.

Rehabilitation Posture Does Not Affect the Outcome of Arthroscopically Treated Acromioclavicular Dislocation

PURPOSE

To assess the effect of the patient's posture (erect or supine) during rehabilitation sessions on pain, function, and the coracoclavicular (CC) distance after arthroscopic treatment of acromioclavicular joint dislocation.

METHODS

Sixty patients with acute type III or V acromioclavicular dislocation injuries were randomly allocated into 2 groups according to their posture during the rehabilitation phase: supine rehabilitation group (SRG) or erect rehabilitation group (ERG). Arthroscopic stabilization with a suspensory fixation device was used in all patients. The visual analog scale (VAS) score was assessed on the first postoperative day and at 1, 3, and 6 months postoperatively. The Constant-Murley score (CMS) was recorded preoperatively and at 3, 6, 12, and 24 months postoperatively. The CC distance was assessed preoperatively; on the first postoperative day; and at 6, 12, and 24 months postoperatively.

RESULTS

No significant differences were found between the 2 groups in terms of the VAS score, CMS, and CC distance changes. A significant improvement over the follow-up phase was identified in the VAS score and CMS in both groups. The CC distance in both groups was significantly reduced from preoperatively (29.34 mm in the ERG and 28.65 mm in the SRG) to the first postoperative day (10.44 mm and 10.11 mm, respectively). However, a statistically significant re-widening of the CC distance (P < .001) occurred within the first 6 months after surgery (13.55 mm in the ERG and 13.50 mm in the SRG) and at 12 months (15.51 mm and 15.80 mm, respectively).

CONCLUSIONS

The patient's posture during early postoperative rehabilitation does not affect the CC distance changes.

LEVEL OF EVIDENCE

Level I, randomized prospective comparative study.

[Effectiveness of arthroscopic assisted double Endobutton "8" buckle fixation in treatment of Rockwood type acute acromioclavicular joint dislocation]

OBJECTIVE

To investigate the short-term effectiveness of arthroscopic assisted double Endobutton "8" buckle fixation in the treatment of Rockwood Ⅲ type acute acromioclavicular joint dislocation.

METHODS

The clinical data of 12 patients with Rockwood Ⅲ type acute acromioclavicular joint dislocation who were treated with arthroscopic assisted double Endobutton "8" buckle fixation between June 2016 and June 2019 were analyzed retrospectively. There were 8 males and 4 females, with an average age of 47.0 years (range, 36-58 years). There were 4 cases of left shoulder and 8 cases of right shoulder. The causes of injury included traffic accident injury in 7 cases and falling injury in 5 cases. The average time from injury to operation was 5.0 days (range, 3-14 days). Before operation and at last follow-up, the shoulder joint activity was recorded; the improvements of function and pain were evaluated by Constant score and visual analogue scale (VAS) score, respectively; the reduction was evaluated by measuring the coracoid spacing of the affected side on the anteroposterior X-ray film of shoulder joint.

RESULTS

All 12 cases were followed up 6-36 months, with an average of 20.6 months. All the incisions healed by first intention. There was no complications such as clavicle and coracoid fractures and Endobuton displacement. At last follow-up, the range of motion of the abduction improved from preoperative (77.5±4.5)° to (162.5±6.5)°, the range of motion of forward flexion improved from (84.1±5.2)° to (169.5±5.8)°, the Constant score improved from 42.5±2.3 to 92.4±2.3, the VAS score improved from 5.4±0.8 to 0.6±0.5, and the coracoid spacing reduced from (20.5±1.4) mm to (9.2±0.6) mm, all showing significant differences ( P<0.05).

CONCLUSION

Arthroscopic assisted double Endobutton "8" buckle fixation for the treatment of Rockwood Ⅲ type acute acromioclavicular joint dislocation is safe, less invasive, and quicker recovery. It can effectively alleviate shoulder pain, significantly improve the mobility of the shoulder joint, and achieve good short-term effectiveness.

Surgical management of Rockwood type 3 acromioclavicular joint injuries: a retrospective comparison of outcomes of suture anchor fixation and double-button fixation techniques

The treatment of type 3 acromioclavicular joint injuries has still controversial issues. In this retrospective study, we aimed to compare the radiological and functional outcomes of the suture anchor and double-button fixation methods for the treatment of type 3 acromioclavicular joint injuries.This study included 20 patients who underwent suture anchor (9 patients) and double-button fixations (11 patients) for isolated type 3 acromioclavicular dislocation. Injuries were classified according to the Rockwood Classification System. Coracoclavicular(CC) distances and anterior translation have been measured pre-operatively and at the 12th month follow-up. Functional evaluation was performed using the DASH, and Constant-Murley scores of the patients were recorded at the12th-month follow-up.The mean age of the patients was 37 (22-50) years in Group 1(double-button group) and 39 (24-56) years in Group 2(suture anchor group). All of the patients were male. There was no statistically significant difference between the DASH and Constant-Murley scores of the 2 groups (P > .05). The mean DASH score of the patients evaluated at the postoperative 12th month was 6.65 (0-38.3) in Group 1 and 2.48 (0-4.2) in Group 2. The mean Constant-Murley score of the patients evaluated at the postoperative 12th month was 89,6 (50-98) in Group 1 and 93,6 (90-98) in Group 2. Comparison of the pre- and post-operative CC distances and pre- and post-operative anterior translation distances of both groups revealed that there was no statistically significant difference between groups regarding postoperative CC distances and anterior translation distances (P > .05).Suture anchor and double-button techniques are reliable treatment methods that are not superior to one another and can yield excellent functional outcomes.

Does the ZipTightTM effective to maintain reduction after the treatment of acute acromioclavicular joint dislocation?

BACKGROUND

The present study evaluated the functional and radiographic outcomes of acute acromioclavicular (AC) joint reconstruction performed using the mini-open technique and a knotless suspensory loop device METHODS:: A total of 25 patients (20 male and 5 female patients; mean age, 30.7 years; standard deviation, 10 years; range, 17-57 years) who fulfilled the inclusion criteria were included in the study. A functional assessment was performed using the Constant and University of California Los Angeles score. The radiologic assessment included standard anterior-posterior views of the AC and coracoclavicular (CC) distances.

RESULTS

The mean follow-up period was 18.6 months (range, 12-23 months). The mean Constant score was 87.2 ± 3.2, and the mean University of California Los Angeles score was 30.1 ± 2.4 at the final follow-up. Radiological evaluation at the last follow-up of the patients: Although there was no statistically significant increase in the AC and CC values of the patients () at the last follow-up, the average CC value in 6 (24%) of the 25 patients was greater than 50% compared with the unaffected side CC and early postoperative CC values. However, there was no statistically significant difference in the Constant and UCLA scores between the 6 patients with reduction loss and the 19 patients with reduction maintenance (P = .86).

CONCLUSIONS

Clinical results of fixation of acute AC joint dislocations using the ZipTight knotless suspensory loop device system and mini-open technique were favorable in terms of functional recovery and pain relief. However, the major disadvantage of this method was radiological loss of AC joint reduction when compared to the contralateral shoulder.

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

Background

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

Materials and methods

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

Results

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

Conclusions

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

Can an acute high-grade acromioclavicular joint separation be reduced and stabilized without surgery? A surgeon's experience

INTRODUCTION

While the management of Rockwood type III injuries is still a topic of debate, high-grade Rockwood type V injuries are mostly treated surgically, to anatomically reduce the acromioclavicular (AC) joint and to restore functionality. In this case report, we present a method for non-operative reduction and stabilization of a high-grade AC joint injury.

CASE

A 31-year-old male orthopaedic resident sustained a Rockwood type V injury during a snowboarding accident. His AC joint was reduced and stabilized with an AC joint brace for six weeks. The brace provided active clavicle depression and humeral elevation. After removal of the brace the AC joint showed a nearly anatomic reduction. Six-month follow-up weighted X-ray views showed an AC joint which had healed in a Rockwood type II position and the patient returned to full pre-injury function with a satisfying cosmetic appearance.

CONCLUSION

Non-operative reduction and stabilization of high-grade AC joint separations seems to be a valuable treatment option. A "closed reduction and external fixation" approach with the aid of a dedicated AC joint brace can reduce the AC joint and keep it in place until ligamentous consolidation occurs, thus improving AC joint stability and cosmetic appearance without surgical intervention.

Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tight rope: randomized comparative study of clinical outcome and cost-effectiveness

PURPOSE

The purpose of this study was to compare clinical outcome and cost-effectiveness between arthroscopic and open repair using TightRope in acromioclavicular joint dislocation III and IV.

PATIENTS AND METHODS

Fifty-two patients with acute acromioclavicular joint dislocation type III and IV were included. Patients were randomly allocated to either of 2 groups: Arthroscopic Repair Group (ARG) and Open Repair Group (ORG). Constant-Murley Score (CMS), visual analog scale (VAS) score, and coracoclavicular (CC) distance were measured preoperatively and 3 months, 6 months, 1 year, and 2 years postoperatively.

RESULTS

CMS increased from 40.68 for the ARG and 40.70 for the ORG preoperatively to 84.18 and 84.45 after 2 years from operation. VAS score decreased from 60.59 for the ARG and 64.50 for the ORG 1 day after surgery to 18.04 and 17.87 respectively after 6 months. CC distance decreased from 29.27 mm in the ARG and 28.16 mm in the ORG preoperatively to 9.86 mm in the ARG and 10.54 mm in the ORG on postoperative day 1. Rewidening of the CC distance occurred after 6 months (13.27 mm for the ARG and 13.62 mm for the ORG) and 1 year postoperatively (15.77 for the ARG and 15.41 for the ORG) but remained stable at final follow-up. There was a significant difference in surgical time (80.00 minutes in the ARG compared to 52.79 minutes in the ORG) and cost of consumables (US$1729.95 in the ARG compared to US$851.87 in the ORG).

CONCLUSION

Open and arthroscopic repair of acute acromioclavicular joint dislocation yielded good clinical results, yet the arthroscopic technique is more expensive and has a longer surgical time.

Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques

BACKGROUND

Acromioclavicular (AC) instability is a frequent injury affecting young and athletic populations. Symptomatic, high-grade dislocations may be managed by a myriad of operative techniques that utilize different grafts to achieve reduction. Comparative data are lacking on the ability of these techniques to achieve excellent patient outcomes and stable AC reduction and to minimize complications.

PURPOSE

To systematically review the outcomes and complications of different techniques of AC joint reconstruction.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The MEDLINE, Scopus, Embase, and Cochrane Library databases were accessed to perform a systematic review of the scientific literature from 2000 to 2018 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following keywords: "acromioclavicular" and "reconstruction." Included articles were evaluated for loss of reduction, complication rate, revision rate, and change in coracoclavicular distance. Articles were stratified by graft and surgical material used: suture only, Endobutton with suture, TightRope, GraftRope, synthetic artificial ligament, tendon graft, and Weaver-Dunn coracoacromial ligament transfer. These outcomes were pooled using a random-effects model and stratified by surgical technique and arthroscopic versus open reconstruction.

RESULTS

Fifty-eight articles were included in the analysis, with 63 homogeneous populations composed of 1704 patients. The mean age was 37.1 years (range, 15-80 years) with a mean follow-up of 34.3 months (range, 1.5-186 months). The overall failure rate was 20.8% (95% CI, 16.9%-25.2%). The overall pooled complication rate was 14.2% (95% CI, 10.5%-18.8%). The most common complications were infection (6.3% [95% CI, 4.7%-8.2%]), fracture to the coracoid or distal clavicle (5.7% [95% CI, 4.3%-7.6%]), and hardware/button failure (4.2% [95% CI, 3.1%-5.8%]). There were no differences between arthroscopic and open techniques in regard to loss of reduction (P = .858), overall complication rate (P = .774), and revision rate (P = .390). Open surgery had a greater rate of clavicular/coracoid fractures than arthroscopic surgery (P = .048). Heterogeneity, best assessed from the pooled loss of reduction, was measured as I² = 64.0%.

CONCLUSION

Open and arthroscopic AC joint reconstruction techniques have no differences in loss of reduction, the complication rate, and the revision rate based on the available literature. Complications are significant, and profiles vary between surgical techniques, which should be evaluated in the decision making of selecting the technique.

Motion Tracking for Quantitative and Qualitative Assessment of Upper Limb Movements Following Acromioclavicular Joint Ligament Reconstruction: A Pilot Study

Background:

Technological tools as robotic devices and wearable sensors can provide accurate and repeatable measurements of physical variables (e.g., position, velocities, forces) which can be used for quantitative and qualitative assessment of movement analysis and upper limb motor performance.

Objective:

The study aims to propose a quantitative and qualitative assessment of upper limb motor performance by means of seven kinematic parameters recorded by a passive mechatronic device in patients who underwent a surgical procedure for ligament reconstruction following acromioclavicular joint dislocation.

Method:

Five patients (mean age: 40 ± 12 years) with acromioclavicular joint dislocation were enrolled.

A passive end-effector mechatronic device characterized by 7 degrees of freedom and designed for the assessment of upper limb motor performance - especially for measuring the hand position in three-dimensional space - was used.

The Constant-Murley score and seven kinematic parameters were used as clinical outcome measure and quantitative and qualitative assessment, respectively.

Results:

The preliminary results of this study show no significant differences between the impaired arm and unimpaired arm: the end-effector passive mechatronic device used in this study is able to provide an overall assessment of the upper limb motor performance following shoulder impairment.

Conclusion:

The motion tracker can be easily used as effective tool for quantitative and qualitative assessment of upper limb motor performance, even several years after the surgical operation.

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.

Surgical treatment of acute type V acromioclavicular joint dislocations in professional athletes: an anatomic ligament reconstruction with synthetic implant augmentation

BACKGROUND

Most acromioclavicular (AC) joint injuries occur in men in their third decade of life during high-speed or high-impact body contact sports. The management of acute complete AC joint dislocation is surgical. Current surgical techniques include anatomic reconstruction of the main restraints of the AC joint and aim to improve functional outcomes and to reduce the complication rate.

METHODS

We present 10 cases of acute type V AC joint dislocation in professional athletes treated surgically with anatomic reconstruction of the coracoclavicular and AC ligaments and augmentation with the use of a synthetic polyester tape. The minimum follow-up of the patients was 2 years (mean, 48 months; range, 24-86 months). The postoperative functional outcome was assessed at 1 year and 2 years using the Constant-Murley, American Shoulder and Elbow Surgeons, and modified University of California-Los Angeles scoring systems.

RESULTS

In all cases, the postoperative scores were significantly improved (P < .005 in all comparisons with the preoperative scores), and all patients returned to their preinjury high level of activity 6 months postoperatively. Radiographs at 1 month and 6 months revealed the maintenance of reduction. There were no complications.

CONCLUSION

According to the results of our series of patients, demanding cases of acute AC joint dislocation Rockwood type V, in professional athletes, require anatomic fixation of both coracoclavicular and AC ligaments for return to sports as soon as possible and at the preinjury level of performance.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Comparison of surgical outcomes between fixation with hook plate and loop suspensory fixation for acute unstable acromioclavicular joint dislocation: a systematic review and meta-analysis

Treatment of acute (≤4 weeks) high-grade acromioclavicular (AC) joint separation (types III-VI) is still controversial. Currently, the two modern techniques that are widely used include hook plate fixation and coracoclavicular (CC) ligament fixation using a suspensory loop device (tightrope, synthetic ligament or absorbable polydioxansulfate sling). These techniques are both reported to have superior clinical outcomes. This systematic review and meta-analysis aimed to assess and compare clinical outcomes of hook plate fixation versus fixation of the CC ligament using a loop suspensory fixation (LSF) device for the treatment of AC joint injury. These clinical outcomes consist of the Constant-Murley score (CMS), pain visual analog score (VAS) and postoperative complications. Relevant comparative studies were identified from MEDLINE and Scopus from inception to October 5, 2015. Five of 571 studies were eligible; 5, 3, 3, and 5 studies were included in the pooling of CMS, pain VAS, surgical time and postoperative complications, respectively. The unstandardized mean difference (UMD) of the CMS for LSF was 4.43 [95 % confidence interval (CI) 0.73, 8.14], which was statistically significantly higher than the CMS in hook plate fixation. For VAS, the UMD was 0.02 points (95 % CI -3.54, 3.73) higher than LSF but without statistical significance. The surgical time of LSF was 16.21 min (95 % CI 6.27, 26.15) statistically significantly higher than hook plate fixation. LSF had a lower chance of postoperative complications by 0.62 units (95 % CI 0.30, 1.32) when compared to hook plate fixation, but this also was not statistically significant. In acute high-grade AC joint injuries, loop suspensory fixation had higher postoperative functional CMS and mean surgical time when compared to hook plate fixation. However, for postoperative VAS and complication rates, there were no statistically significant differences between groups.

Double-button Fixation System for Management of Acute Acromioclavicular Joint Dislocation

BACKGROUND

Surgical treatments for acromioclavicular (AC) joint dislocation present with some complications. The present study was designed to evaluate the double-button fixation system in the management of acute acromioclavicular joint dislocation.

METHODS

This cross sectional study, done between February 2011 to June 2014, consisted of 28 patients who underwent surgical management by the double-button fixation system for acute AC joint dislocation. Age, sex, injury mechanism, dominant hand, side with injury, length of follow up, time before surgery, shoulder and hand (DASH), constant and visual analogue scale (VAS) scores, and all complications of the cases during the follow up were recorded.

RESULTS

The mean age of patients was 33.23±6.7 years. Twenty four patients (85.71%) were male and four (14.28%) were female. The significant differences were observed between pre-operation VAS, constant shoulder scores and post-operation measurements. There were not any significant differences between right and left coracoclavicular, but two cases of heterotrophic ossifications were recorded. The mean follow-up time was 16.17±4.38 months.

CONCLUSION

According to the results, the double-button fixation system for management of acute acromioclavicular joint dislocation has suitable results and minimal damage to the soft tissues surrounding the coracoclavicular ligaments.

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.

Operative treatment of acute acromioclavicular dislocations Rockwood III and V-Comparative study between K-wires combined with FiberTape(®) vs. TightRope System(®)

INTRODUCTION

Acromioclavicular (AC) joint dislocations usually occur in a young active population as a result of a fall on the shoulder. Rockwood divided these dislocations into six types. Optimal treatment is still a matter of discussion. Many operative techniques have been developed, but the main choice is between open and minimally-invasive arthroscopic procedures. The aim of this study was to compare two different surgical methods on two groups of patients to find out which method is superior in terms of benefit to the patient. The methods were evaluated through objective and subjective scores, with a focus on complications and material costs.

MATERIAL AND METHODS

A retrospective two-centre study was conducted in patients with acute AC joint dislocation Rockwood types III and V. The two methods conducted were an open procedure using K-wires combined with FiberTape(®) (Arthrex, Naples, USA) (Group 1) and an arthroscopic procedure using the TightRope System(®) (Arthrex, Naples, USA) (Group 2). Groups underwent procedures during a two-year period. Diagnosis was based on the clinical and radiographic examination of both AC joints. Surgical treatment and rehabilitation were performed.

RESULTS

Sixteen patients were included in this study: Group 1 comprised 10 patients, all male, average age 41.6 years (range 17-64 years), Rockwood type III (eight patients) and Rockwood type V (two patients); Group 2 had six patients, one female and five male, average age 37.8 years (range 18-58 years), Rockwood type III (two patients) and Rockwood type V (four patients). Time from injury to surgery was shorter and patients needed less time to return to daily activities in Group 1. Duration of the surgical procedure was shorter in Group 2 compared with Group 1. Complications of each method were noted. According to the measured scores and operative outcome between dislocation Rockwood type III and V, no significant difference was found. Implant material used in Group 2 was 4.7 times more expensive than that used in Group 1.

CONCLUSION

Both methods offer many advantages with satisfying evaluated scores. K-wires with FiberTape(®) offer a shorter period for complete recovery and a significantly more cost-effective outcome, whereas the TightRope System(®) offers shorter operative procedure, better cosmetic result and avoidance of intraoperative fluoroscopy.

Biomechanical evaluation of coracoid tunnel size and location for coracoclavicular ligament reconstruction

PURPOSE

The purpose of this study was to determine the effect of coracoid tunnel size and location on the biomechanical characteristics of cortical button fixation for coracoclavicular ligament reconstruction.

METHODS

Thirteen matched pairs of cadaveric scapulae were used to determine the effects of coracoid tunnel size, and 6 matched pairs were used to determine the effects of coracoid tunnel location. For tunnel size, a 4.5-mm hole was drilled in the base of the coracoid of one scapula and a 6-mm hole was drilled in the contralateral scapula. For tunnel location, 2 holes were drilled: (1) The first group received a hole centered in the coracoid base and a hole 1.5 cm distal from the first, along the axis of the coracoid. (2) The second group received holes that were offset anteromedially from the first set of holes (base eccentric and distal eccentric). A cortical button-suture tape construct was placed through each tunnel, and constructs were then loaded to failure.

RESULTS

For tunnel size specimens, load at ultimate failure was significantly greater for the 4.5-mm group compared with the 6-mm group (557.6 ± 48.5 N v 466.9 ± 42.2 N, P < .05). For tunnel location, load at ultimate failure was significantly greater for the centered-distal tunnel group compared with the eccentric-distal group (538.1 ± 70.2 N v 381.0 ± 68.6 N, P < .05).

CONCLUSIONS

A 4.5-mm tunnel in the coracoid provided greater strength for cortical button fixation than a 6-mm tunnel. In the distal coracoid, centered tunnels provided greater strength than eccentric tunnels.

CLINICAL RELEVANCE

When performing cortical button fixation at the coracoid process for coracoclavicular ligament reconstruction, a 4.5-mm tunnel provides greater fixation strength than a 6-mm tunnel. The base of the coracoid is more forgiving than the distal coracoid regarding location.

Arthroscopy-assisted reconstruction of coracoclavicular ligament by Endobutton fixation for treatment of acromioclavicular joint dislocation

OBJECTIVE

The aim of this study was to evaluate the clinical outcomes of arthroscopy-assisted reconstruction of the coracoclavicular (CC) ligament using Endobutton for treating acromioclavicular (AC) joint dislocation.

METHODS

From March 2012 to May 2013, a total of 22 patients with fresh AC joint dislocation (Rockwood type III and type V) were treated with arthroscopy-assisted Endobutton reconstruction of the CC ligament. The regular post-operation follow-up was performed. Shoulder joint function was assessed with Constant-Murley scores. Postoperative efficacy of the surgery was evaluated using the Karlsson criterion.

RESULTS

The 22 patients were followed postoperatively for an average of 24 months (16-31 months). Among them, 20 patients achieved good functional recovery with no pain. Two patients had slight pain in the acromion during shoulder joint motion with limited abduction at 3 months, both of whom had recovered at 6 months. Radiography confirmed anatomical reduction of the AC joint in all patients. At 1 year, the Constant-Murley scores were 93.1 ± 2.4 points on the injured side versus 94.2 ± 2.7 points on the uninjured side. The difference did not reach statistical significance (P > 0.05). Postoperative Karlsson evaluation ranked 20 patients (90.9 %) as grade A and 2 as grade B (9.1 %) at the 3-month follow-up. All patients had become grade A at 6 months. None of the patients had brachial plexus or peripheral vascular injuries.

CONCLUSION

Arthroscopy-assisted reconstruction of the coracoclavicular ligament by Endobutton fixation is a safe, easy method for treating AC joint dislocation. It provides reliable fixation, causes little trauma, and has a fast recovery.