Arthroscopic Acromioclavicular Joint Reconstruction Using Knotless Coracoclavicular Fixation and Soft-Tissue Anatomic Coracoclavicular Ligament Reconstruction

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).

Reliability of the ISAKOS Modification to Subclassify Rockwood Type III Acromioclavicular Joint Injuries

Background

To improve clinical management, the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) developed a specific subclassification of Rockwood type III acromioclavicular (AC) injuries: IIIA (no overriding distal clavicle) and IIIB (overriding distal clavicle).

Purpose/Hypothesis

The study aimed to determine the inter- and intraobserver reliability of the radiographic classification proposed by ISAKOS for AC injuries. It was hypothesized that the strength of agreement for the ISAKOS modification will be substantial to almost perfect.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

We evaluated 40 radiographs of all types of AC joint injuries from patients at a single institution. The images were distributed to 6 shoulder and elbow fellowship-trained orthopaedic surgeons, along with standardized assessment questionnaires. The evaluators measured the bilateral coracoclavicular distance and the coracoclavicular ratio and classified the severity of the injuries according to the modified ISAKOS Rockwood classification. Four of the surgeons repeated the evaluation 6 weeks later to calculate intraobserver agreement. The kappa (κ) statistic was calculated for categorical inter- and intraobserver reliability. Intraclass correlation coefficient (ICC) estimates were calculated for the reliability of the coracoclavicular distance measurement. A 2-tailed test was performed to assess statistical significance.

Results

Overall interobserver agreement was substantial (κ = 0.637; 95% CI, 0.595-0.680) among the 6 evaluators, and intraobserver agreement was also substantial among the 4 evaluators (κ = 0.616; 95% CI, 0.549-0.638). The interobserver agreement for evaluating types IIIA and IIIB was fair (κ = 0.215; 95% CI, 0.135-0.295) and moderate (κ = 0.473; 95% CI, 0.393-0.553), respectively. The agreement on the coracoclavicular distance measurements was excellent among the 6 evaluators on both the affected side (ICC, 0.982; 95% CI, 0.970-0.990) and the unaffected side (ICC, 0.930; 95% CI, 0.894-0.958).

Conclusion

Substantial agreement was found when categorizing AC joint injuries using the ISAKOS modification of the Rockwood classification, with excellent reliability demonstrated for the quantitative assessment of vertical displacement of the clavicle. Visual examination was unreliable in differentiating type IIIA injuries from type IIIB injuries.

Arthroscopic-Assisted Acromioclavicular Joint Reconstruction

There are many documented techniques for the surgical treatment of a chronic acromioclavicular (AC) joint reconstruction, but unfortunately, there is no gold standard. Treatment options include hook plates, allograft reconstruction, and suture fixation, among many others.

This technique is an innovative method for looping the allograft around the coracoid and clavicle and using the hook plate for fixation. This avoids any drilling within the clavicle or coracoid, therefore decreasing the risk of fracture and ensuring the reduction of the AC joint.

Addressing Arthroscopic-Assisted Acromioclavicular Joint Reconstruction in the Beach Chair Position With Concomitant Labral Pathology in the Lateral Decubitus Position

High-grade Acromioclavicular (AC) injuries are complete dislocations, involving ruptures of the AC and coracoclavicular ligaments. They occur following trauma after a fall, direct-blow to an adducted arm, or indirectly by falling onto an abducted, outstretched extremity. Given this traumatic etiology, additional intra-articular pathologies can arise and may go unnoticed because of the painful and prominent AC joint (ACJ). Previous studies have evaluated patients with high-grade ACJ injuries with diagnostic arthroscopy at the time of an ACJ reconstruction. They found associated injuries to the labrum/biceps, rotator cuff, and articular cartilage. The arthroscopic-assisted ACJ reconstruction (AA-ACJR) technique has made it possible to identify the associated injuries and treat them concurrently. The previous studies have performed this reconstruction in the beach chair position (BCP) and have addressed the concomitant pathology in the same position. As opposed to the BCP, the lateral decubitus position (LDP) allows for easier application of traction to the arm and, thus, improves visualization of the glenoid, especially the inferior and posteroinferior portions. It is imperative to gain appropriate access to the inferior glenoid for anchor placement to address this component of traumatic instability. We present the technique for addressing high-grade ACJ injuries with AA-ACJR in the BCP preceded by labral repair in the LDP.

The Evolution of Arthroscopic Rotator Cuff Repair

Over the past 30 years, arthroscopic rotator cuff repair (ARCR) has evolved to become the gold standard in treating rotator cuff pathology. As procedural concepts of ARCR continue to improve, it is also continually compared with the open rotator cuff repair as the historical standard of care. This review highlights the evolution of ARCR, including a historical perspective; the anatomic, clinical, and surgical implications of the development of an arthroscopic approach; how arthroscopy improved some of the problems of the open approach; adaptations in techniques and technologies associated with ARCR; future perspectives in orthobiologics as they pertain to ARCR; and lastly, the clinical improvements, or lack of improvements, with all of these adaptations.

Acromioclavicular Joint Reconstruction with Recessed Clavicular Implant Technique Guide

Acromioclavicular (AC) joint injuries are common and often require operative intervention. Although there are many described surgical techniques, there remains a lack of consensus on the optimal technique. The purpose of this Technical Note is to provide our preferred method of AC reconstruction with a recessed clavicular implant and semitendinosus allograft, which mitigates hardware pain associated with arthroscopic techniques.

Good to Excellent Functional Outcome and High Return to Sports Rate after Operative Treatment of Unstable Lateral Clavicle Fractures: Comparison of Two Coracoclavicular Button Fixation Techniques

Purpose: Operative therapy for unstable lateral clavicle fractures is necessary to reduce the risk of bony non-union. Irritation and restriction during sportive activities due to the implanted materials are a common reason for impaired function and implant removal. The aim of this study was to gain information on functional outcome and time until return to sport (RTS) after surgical treatment of unstable lateral clavicle fractures, comparing two coracoclavicular button techniques. Methods: A retrospective chart review of patients who were consecutively treated for unstable lateral clavicle fractures at our level one trauma center from 2014 to 2018 was conducted. Two different surgical techniques were evaluated and compared. Group 1 was treated using a locking compression plate and knotted DogBone™ Button, while group 2 received an LCP and knotless DogBone™ Button. Functional outcome (ASES (American Shoulder and Elbow Score), Constant-Score, DASH (Disability of Arm, Shoulder and Hand), MSQ (Munich Shoulder Questionnaire) and SPADI (Shoulder Pain and Disability Index) and time until RTS were investigated and compared between both groups, 1 year postoperatively. Results: A total of 56 patients (n = 35 group 1, n = 21 group 2) with a mean age of 45.1 ± 14.6 years met the inclusion criteria. Functional outcome reached good to excellent results (ASES 94.7 ± 9.8, Constant Score 85.1 ± 8.1, DASH 5.5 ± 8.4, MSQ 90.9 ± 7.2, SPADI 96.1 ± 5.7). Implant removal rates were higher in group 1 (48.3% vs. 35.3%) yet without statistical significance (p = 0.122). All patients returned to sports postoperatively with a mean time period until return to sport of 4.6 (3–9) months. Conclusion: Locking compression plating and coracoclavicular fixation using a knotless Dogbone™ technique provides good to excellent functional outcomes, a high and fast rate of return to sport and lower irritation rates compared to the knotted DogBone™ technique.

Mid-Term Outcomes of Arthroscopically-Assisted Anatomic Coracoclavicular Ligament Reconstruction Using Tendon Allograft for High-Grade Acromioclavicular Joint Dislocations

PURPOSE

The purposes of this study were to assess clinical and radiographic outcomes of arthroscopically-assisted, anatomic coracoclavicular ligament reconstruction using tendon allograft (AA-ACCR) for the treatment of Rockwood type III-V injuries at minimum 2-year follow-up and to perform subgroup analyses of clinical and radiographic outcomes for acute versus chronic and type III versus type IV-V injuries.

METHODS

In this retrospective study of prospectively collected data, patients who underwent primary AA-ACCR for the treatment of type III-V dislocations and had minimum 2-year follow-up were included. Preoperative and postoperative patient-reported outcome scores (PROs) were collected, including American Shoulder and Elbow Surgeons score, Single Numeric Assessment Evaluation score, Short Form-12 Physical Component Summary, Quick Disabilities of the Arm Shoulder and Hand score, and patient satisfaction. Preoperative and postoperative coracoclavicular distance (CCD) was obtained. PROs and CCD were reported for the total cohort and for the subgroups. Complication and revision rates were demonstrated.

RESULTS

In total, 102 patients (10 women, 92 men) with a mean age of 45.0 years (range, 18-73 years) were included. There were 13 complications (12.7%) resulting in revision surgery. After exclusion of revised patients, PROs were available for 69 (77.5%). At mean follow-up of 4.7 years (range, 2.0-12.8 years), all PROs improved significantly (P < .001). Median patient satisfaction was 9.0 (interquartile range, 8.0-10.0). Median preoperative to postoperative CCD decreased significantly (P < .001). Subgroup analyses revealed significant improvements in all PROs and CCD from preoperative to postoperative for both acute and chronic, and type III and type IV-V dislocations (P < .05) with no significant differences in postoperative PROs and satisfaction between (P > .05).

CONCLUSION

AA-ACCR for high-grade acromioclavicular joint injuries resulted in high postoperative PROs and patient satisfaction with significant improvements from before to after surgery in those who did not undergo revision surgery. Furthermore, subgroup analyses revealed that acute and chronic, and type III and type IV-V injuries benefitted similarly from AA-ACCR.

LEVEL OF EVIDENCE

Level IV; therapeutic case series.

Editorial Commentary: Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction Leads to Improved Patient-Reported Outcomes, But Patient Satisfaction Is a Harder Threshold to PASS

There are numerous described techniques for surgical management of high-grade acromioclavicular (AC) joint injuries, and the associated clinical outcomes can be quite variable. Contemporary techniques are typically directed at anatomic reconstruction of the coracoclavicular (CC) ligaments through either an arthroscopy-assisted or an open approach. Most patients treated with acute surgery improve, whereas in chronic cases, the majority improve, but a significant number have persistent recurrent deformity due to loss of anatomic reduction. In addition, whether acute or chronic, over one quarter of patients do not have a PASS (patient acceptable symptomatic state). Of interest, PASS may not primarily be related to the final deformity in terms of coracoclavicular distance, and investigation is still required in terms of the effect of anteroposterior or rotational instability of the AC joint after injury and surgery. Finally, PASS values for AC separation are not well established, resulting in a current limitation of the strength of applying threshold values to this pathology.

Free Hand Drilling Technique to Enhance Central Position of Tunnels in Arthroscopic Acromioclavicular Joint Fixation Using TightRope System

Acromioclavicular joint (ACJ) dislocations represent one of the most common lesions in the shoulder. Arthroscopic reduction and ACJ fixation with the button system is one of the most used techniques for displaced and unstable dislocations. Difficulties with placing the tunnels in the central and correct position of the clavicular and coracoid can occur with the use of a guide, which can result in fractures, eccentric tunnel position, cortical rupture, prolongation of surgical times with its complications as bleeding, tissue infiltration, difficult visualization, and increased risk of infection. Prior free hand central tunnel placement in the clavicle with a 3.2 mm drill helps to keep in place the pin guide over the superior cortical of coracoid with reduction of guide movement to enhance the correct position of tunnel in the coracoid process avoiding bone complications.

Optimal Management of Acromioclavicular Dislocation: Current Perspectives

Injuries to the acromioclavicular (AC) joint are common and mostly involve younger, male individuals. Whereas the majority of AC joint dislocations can be treated nonoperatively with a trial of immobilization, pain medication, cryotherapy, and physiotherapy, there are patients that do not respond well to conservative management and may require surgical treatment. Identifying and treating these patients according to the type and chronicity of AC joint dislocation is paramount. To date, a myriad of surgical techniques have been proposed to address unstable AC joint dislocations and are indicative of the uncertainty that exists in optimal management of these injuries. Historically research has focused on the restoration of the coracoclavicular ligament complex. However, recently the importance of the acromioclavicular capsule and ligaments has been emphasized. This review aims to provide the reader with an overview of current treatment strategies and research, as well as future perspectives.

Arthroscopic Coracoclavicular Ligament Reconstruction of Chronic Acromioclavicular Dislocations Using Autogenous Semitendinosus Graft: A Two-Year Follow-up Study of 58 Patients

Purpose

To determine the results of operatively treated chronic acromioclavicular (AC) joint dislocations after 2-year follow-up.

Methods

Fifty-eight patients with chronic acromioclavicular separations underwent arthroscopic coracoclavicular ligament reconstructions using semitendinosus autografts. Constant and Simple Shoulder Test scores were determined before and 2 years after surgery as a part of standard clinical practice. General patient satisfaction with the outcome (poor, fair, or excellent) also was assessed. In addition, for purposes of routine clinical follow-up, the coracoclavicular distance was measured from the inferior cortex of the clavicle to the superior cortex of the coracoid using anteroposterior radiographs taken 2 years after surgery. The results were compared with postoperative radiographs and changes in the distance were recorded. The clavicular drill hole was similarly measured 2 years after surgery to detect possible tunnel widening.

Results

The mean preoperative Constant score increased from a preoperative mean of 52.6 ± 16.5 to 94.7 ± 7.9 at 2 years postoperatively (P = .000). The Simple Shoulder Test score increased from a preoperative mean of 7.7 ± 1.64 to 11.8 ± 0.7 (P = .000). The mean coracoclavicular distance increased from 10.5 ± 3.4 to 12.4 ± 3.9 mm (P = .009). The diameter of the clavicular drill hole increased from 6.0 mm to a mean of 8.4 mm. Two coracoid fractures were observed, but no clavicular fractures. One patient experienced a deep infection, leading to total reconstruction failure, and 2 patients had superficial postoperative infections. Forty-five patients (85%) reported excellent subjective outcomes, and 8 (15%) reported a fair outcome.

Conclusions

The outcomes of this series of coracoclavicular ligament reconstruction were favorable and the number of serious complications was small. However, clavicular wound issues were a significant problem. Coracoclavicular ligament reconstruction is a challenging procedure, but satisfactory results can be achieved with careful patient selection and good technique.

Level of Evidence

Level IV, therapeutic case series

Voluntary acromioclavicular joint dislocation: a case report and literature review

Voluntary glenohumeral dislocations have been reported in academic literature; however, voluntary dislocations of the acromioclavicular joint are rare, with four cases previously reported in published literature. We present a case of an adolescent female with bilateral, atraumatic acromioclavicular joint dislocation who ultimately was treated with arthroscopic reconstruction of the coracoclavicular ligament. The case is discussed in addition to a review of previously reported cases of voluntary acromioclavicular joint dislocations. Treatment methods in each of the four previously reported cases are discussed with recommendation for surgeons that may encounter this rare shoulder problem in future patients.

Arthroscopic Coracoacromial Ligament Transfer Augmented With Suspensory V-Shaped Fixation System for Chronic Acromioclavicular Joint Dislocation

Chronic acromioclavicular joint dislocations (ACJDs) develop when there is failure of conservative treatment, failed surgical treatment of acute ACJD, or simply missing the treatment in the acute healing phase. There is wide agreement that mechanical fixation alone in chronic ACJD is not sufficient and biological augmentation is necessary. Various arthroscopic techniques for reconstruction of the coracoclavicular ligament have been described, but allografts are expensive, are not available in all centers, carry the risk of disease transmission, and are "dead tissue" with a poor capacity for healing. Autografts are associated with donor-site morbidity and avascular structures. Moreover, these grafts are associated with a high risk of clavicular or coracoid fractures owing to large tunnels. We present an arthroscopic technique to transfer the coracoacromial ligament to the inferior surface of the lateral part of the clavicle in chronic ACJD, augmented with 2 clavicular buttons and a single coracoid button in a V-shaped configuration. The technique has various advantages including better stabilization, anatomic reconstruction, and a minimal risk of fracture of the coracoid and clavicle with small tunnels, using a vascularized graft with arthroscopic control of reduction.

Arthroscopic Acromioclavicular Joint Reconstruction With TightRope and FiberTape Loop

High-grade acromioclavicular (AC) injuries are frequent in the active population, and their treatment in the acute setting has reduced sequelae such as chronic pain, functional impairment, and inability to return to sports. Multiple techniques have been described to achieve reduction and fixation of the AC joint, but still there is no consensus. The objective of this Technical Note is to describe the reduction and internal fixation under arthroscopic assistance of the AC joint with the use of a double button implant plus high-strength tape in the acute setting.

Biomechanical Evaluation of a Single- Versus Double-Tunnel Coracoclavicular Ligament Reconstruction With Acromioclavicular Stabilization for Acromioclavicular Joint Injuries

BACKGROUND

An anatomic double-tunnel (DT) reconstruction technique has been widely adopted to reconstruct the ruptured coracoclavicular (CC) ligaments seen with high-grade acromioclavicular (AC) joint injuries. However, the anatomic DT reconstruction has been associated with the risk of clavicle fractures, which may be problematic, particularly for contact athletes. Purpose/Hypothesis: The purpose was to compare a single-tunnel (ST) CC ligament reconstruction for AC joint injuries with the native state as well as with the more established anatomic DT CC ligament reconstruction. The hypothesis was that ST CC ligament reconstruction would demonstrate biomechanical properties similar to those of the native state and the DT CC ligament reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen fresh-frozen human cadaveric shoulders (9 matched pairs) with mean ± SD age of 55.5 ± 8.5 years underwent biomechanical testing. One specimen of each matched pair underwent a ST CC ligament reconstruction and the second, a DT CC ligament reconstruction. The ST and DT CC ligament reconstruction techniques involved a 5-mm distal clavicle excision, avoided coracoid drilling, and utilized a 3.0-mm suture anchor to fix the excess lateral limb to reconstruct the superior AC joint capsule. The ST CC ligament reconstruction technique additionally included a 1.3-mm suture tape to help avoid a sawing effect, as well as a dog-bone button over the clavicular tunnel to increase stability of the construct. All specimens were tested to 70 N in 3 directions (superior, anterior, and posterior) in the intact and reconstructed states. The ultimate load, yield load, stiffness, and mode of failure of the reconstructed specimens were tested.

RESULTS

There were no significant differences in translation at 70 N in the superior ( P = .31), anterior ( P = .56), and posterior ( P = .35) directions between the ST CC ligament reconstruction and the intact state. The ultimate load to failure, yield load, and stiffness in the ST and DT groups were also not significantly different. There were no distal clavicle fractures in load-to-failure testing in the ST or DT group.

CONCLUSION

In this biomechanical study, ST CC ligament reconstruction demonstrates biomechanical properties comparable to the intact state. Additionally, use of the ST CC ligament reconstruction shows biomechanical properties similar to the DT CC ligament reconstruction technique while theoretically posing less risk of clavicle fracture.

CLINICAL RELEVANCE

This study suggests that the ST CC ligament reconstruction has biomechanical properties equivalent to the DT CC ligament reconstruction with less theoretical risk of clavicle fracture.