Current concepts in management of ACJ injuries

Recurrent Anterior Shoulder Dislocation with Coracoid Fracture in an Old Age Male: A Rare Case Report

Introduction

Anterior shoulder dislocation is a common pathology in young males with less prevalence in other age groups. Anterior shoulder dislocation being the most common variety of dislocation among the shoulder dislocation can be managed both conservatively and surgically. Recurrent anterior dislocation in middle-aged males with a coracoid fracture is a rare entity and should be managed with proper pre-operative planning including computed tomography (CT) scan, magnetic resonance imaging (MRI), and surgery.

Case Report

A 65-year-old male is a known case of recurrent anterior dislocation presented with anterior shoulder dislocation 1½ years back. Closed reduction was done. Radiological evaluations such as CT scan and MRI were done which were suggestive of bony Bankart and coracoid fracture which was managed with open Latarjet procedure.

Conclusion

Recurrent anterior shoulder dislocation with a concomitant coracoid fracture is a rare entity in old age, which can be managed with a Latarjet procedure and has a good post-operative outcome.

Type III acromioclavicular dislocation: Mid term results after operative and non-operative treatment

INTRODUCTION

Controversy exists in the literature about the best treatment for type III acromioclavicular dislocations. The aim of this study is to compare functional results between surgical and conservative treatment in type III acromioclavicular joint dislocations.

MATERIAL AND METHOD

We retrospectively evaluated the records of 30 patients from our area with acute type III acromioclavicular dislocations that were treated from January 1st, 2016 to December 31st, 2020. Fifteen patients were treated surgically and 15 conservatively. Follow up mean time was 37.93 months in operative group and 35.73 months in non-operative group. Results obtained on the Constant score was the main variable analysed and results obtained on the Oxford score and the Visual Analogue Scale for pain were the secondary variables. Epidemiological variables were analysed, as well as range of mobility in injured shoulder and subjective and radiological variables (distance between the superior border of the acromion and the superior border of the clavicle's distal end and presence of osteoarthritis in the acromioclavicular joint).

RESULTS

Functional evaluation scores did not show differences between the two groups (Constant: operative 82/non-operative 86.38, p 0.412; Oxford: operative 42/non-operative 44.80, p 0.126) nor did Visual Analogue Scale (operative 1/non-operative 0.20, p 0.345). Subjective evaluation of the injured shoulder was excellent or good in 80% of the patients in both groups. Measurement of the distance between the superior border of the acromion and the superior border of the clavicle's distal end were significantly higher in non-operative group (operative 8.95/non-operative 14.21, p 0.008).

CONCLUSIONS

Although radiographic results were better in the surgical treatment group, functional evaluation scores did not show significant differences between the two groups. These results do not support the routine use of surgical treatment for grade III acromioclavicular dislocations.

[Translated article] Type III acromioclavicular dislocation: Mid term results after operative and non-operative treatment

INTRODUCTION

Controversy exists in the literature about the best treatment for type III acromioclavicular dislocations. The aim of this study is to compare functional results between surgical and conservative treatment in type III acromioclavicular joint dislocations.

MATERIAL AND METHOD

We retrospectively evaluated the records of 30 patients from our area with acute type III acromioclavicular dislocations that were treated from January 1st, 2016 to December 31st, 2020. Fifteen patients were treated surgically and 15 conservatively. Follow-up mean time was 37.93 months in operative group and 35.73 months in non-operative group. Results obtained on the Constant score was the main variable analysed and results obtained on the Oxford score and the Visual Analogue Scale for pain were the secondary variables. Epidemiological variables were analysed, as well as range of mobility in injured shoulder and subjective and radiological variables (distance between the superior border of the acromion and the superior border of the clavicle's distal end and presence of osteoarthritis in the acromioclavicular joint).

RESULTS

Functional evaluation scores did not show differences between the two groups (Constant: operative 82/non-operative 86.38, p 0.412; Oxford: operative 42/non-operative 44.80, p 0.126) nor did Visual Analogue Scale (operative 1/non-operative 0.20, p 0.345). Subjective evaluation of the injured shoulder was excellent or good in 80% of the patients in both groups. Measurement of the distance between the superior border of the acromion and the superior border of the clavicle's distal end were significantly higher in non-operative group (operative 8.95/non-operative 14.21, p 0.008).

CONCLUSIONS

Although radiographic results were better in the surgical treatment group, functional evaluation scores did not show significant differences between the two groups. These results do not support the routine use of surgical treatment for grade III acromioclavicular dislocations.

Current Concepts in Management of Acromioclavicular Joint Injury

Background: The management of acromioclavicular joint injuries requires a thorough understanding of the anatomy and biomechanics of the joint, as well as knowledge of the pertinent physical exam findings and classification to determine an appropriate treatment approach, whether operative or nonoperative. In this article, we present a narrative review of the current state of understanding surrounding these issues. Although there are a large number of options for operative intervention, we additionally present our experience with anatomic coracoclavicular ligament reconstruction (ACCR) with imbrication of the deltoid fascia. Methods: A retrospective review of prospectively collected data on a total of 45 patients who had undergone ACCR between 2003 and 2016 were collected. Results: We found that improvements were seen in American Shoulder and Elbow Surgeons Score (ASES) (53 ± 19 to 81 ± 23), Simple Shoulder Test (SST) (6 ± 3 to 12 ± 13), Constant-Murley (CM) (60 ± 18 to 92 ± 8), and Rowe (67 ± 14 to 89 ± 11) and the mean post-operative SANE score was 86 ± 17. Conclusions: ACCR has the advantage of addressing both horizontal and vertical stability with good outcomes.

Surgical treatment of acromioclavicular joint dislocation of Rockwood III/IV: a retrospective study on clavicular hook plate versus arthroscopic TightRope loop titanium button

PURPOSE

To compare the clinical efficacy of arthroscopic TightRope loop titanium button and clavicular hook plate in the treatment of acromioclavicular joint (ACJ) dislocation of Rockwood III/IV.

METHODS

A retrospective analysis of patients with ACJ dislocation in our hospital from January 2018 to December 2020 was conducted. The patients were assigned to be treated with arthroscopic TightRope loop titanium button (TR group) or clavicular hook plate (HP group). The preoperative, intraoperative and postoperative data and imaging findings of the two groups were compared.

RESULTS

A total of 58 eligible patients were enrolled in this study. Compared with HP group, TR group had shorter incision length and less blood loss during operation. Postoperative follow-up ranged from 12 to 24 months (mean 15.4 months). At 6 months and 12months postoperatively, compared with HP group, TR group had lower VAS and higher CMS, and the difference was statistically significant. At 12 months postoperatively, compared with HP group, TR group had lower ACJ gap and coracoclavicular joint(CCJ) distance, and the difference was statistically significant.In HP group, there were 3 cases of subacromial impact, 1 case of redislocation, 2 cases of traumatic arthritis and 2 cases of wound infection. There was 1 case of redislocation in TR group.

CONCLUSIONS

Compared with clavicular hook plate, arthroscopic TightRope loop titanium button is minimally invasive, safe and effective in the treatment of ACJ dislocation, and has a good trend in clinical application.

Risk for Fracture with Acromioclavicular Joint Reconstruction and Strategies for Mitigation

Acromioclavicular (AC) joint injuries are a common cause of shoulder pain, especially among athletes. Surgical reconstruction of the AC joint can lead to complications such as fracture of the coracoid process, clavicle or acromion, which can negatively affect the patient's outcome. The purpose of this review is to discuss the risk factors for fractures associated with AC joint reconstruction, as well as the strategies that can be used to mitigate this risk. Risk factors for fractures include low mineral density, coracoid/clavicle drilling, larger holes in the coracoid, and the number of tunnels used for reconstruction.

Management of Acromioclavicular Joint Injuries: A Historic Account

There has been a rapid evolution in best practice management of acromioclavicular (AC) joint injuries. AP, Zanca, scapular Y, and dynamic axillary radiographic views provide optimal visualization of the joint and may assess for the presence of horizontal AC instability. Severity of AC joint pathology is classified according to the 6-tier Rockwood scoring system. Over 160 surgical techniques have been described for AC joint repair and reconstruction in the last decade; as a result, determining the optimal treatment algorithm has become increasingly challenging secondary to the lack of consistently excellent clinical outcomes.

Clinical outcomes for grades III-V acromioclavicular dislocations favor double-button fixation compared to clavicle hook plate fixation: a systematic review and meta-analysis

INTRODUCTION

The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing double-button suture fixation to hook plate fixation for types III-IV acromioclavicular joint dislocation.

METHODS

Systematic review of Medline, Embase, Scopus, and Google Scholar, including all levels 1-3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were included. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. MINORS and modified Coleman Methodology Score (CMS) were used to assess within study quality. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics.

RESULTS

Fifteen studies were included. Three of the four included LOE II and eleven of the LOE III studies had a high risk of bias. Study quality was considered poor and fair for 67% by MINORS criteria and 93% for CMS criteria. The pooled estimate (SMD 0.662) for all clinical outcomes was statistically significant and in favor of button repair (p = 0.0001). The pooled estimate (SMD 0.662) for all VAS pain scores was statistically significant, again in favor of button repair (p = 0.001).

CONCLUSIONS

The results of this meta-analysis demonstrated significantly better outcomes of button repair for acute ACJ dislocations when compared to clavicle hook plate. Button repair is also associated with a 2.2 times lower risk for complications. However, risk of bias is high, and study quality within and between studies was low. These results, therefore, must be viewed with caution.

LEVEL OF EVIDENCE

Level III; systematic review and meta-analysis.

Operative vs. conservative treatment of AC-Joint Dislocations Rockwood grade ≥ III -An economical and clinical evaluation

INTRODUCTION

Acromioclavicular joint dislocations (ACD) are one of the most common shoulder injuries. There is no consensus in how to treat higher graded ACD ≥ Rockwood grade III. This study compares operative versus conservative treatment regarding costs and clinical outcome parameters.

MATERIALS AND METHODS

This retrospective, consecutive case-control-study includes 14 patients. Seven operatively treated patients were matched, by Rockwood grade, with seven conservatively treated patients. The cost was extracted out of the clinical- and insurance-based cost sheets and furthermore these include the loss of earnings. Clinical examination, demographic data as well as different outcome-questionnaires were recorded.

RESULTS

There were no significant differences between operative and conservative treated patients for outcome Questionnaires. Of note, there was a significantly higher incidence of tenderness over the AC-joint (p = 0.0038) postoperatively. As expected, economical evaluation showed various findings in favor of the conservative treatment. The costs for medical services (11012.39vs.1163.81USD; p = 0.0061), days of hospitalization (3.3vs.0days; p < 0.0001); total cost for medical treatment (30262.17 vs. 7833.82 USD; p = 0.0358) were significantly higher in the operative group.

CONCLUSION

Even with a limited case number and a retrospective study design almost all clinical results were equal in both groups. Operative therapy of higher graded ACDs (Rockwood > III) compared to conservative is economically inefficient. Under consideration of clinical comparable results, indications for operative treatment should be set very carefully.

Long-term Clinical Outcomes After TightRope Versus Hook Plate Fixation for Acute Acromioclavicular Joint Dislocation

Background

There is limited information regarding the long-term efficacy of techniques for surgical fixation after acromioclavicular (AC) joint dislocation.

Purpose

To evaluate the efficacy of hook plate (HP) and TightRope (TR) fixation for acute AC joint dislocations by comparing the long-term clinical and radiological patient outcomes.

Study Design

Cohort study, Level of evidence, 3.

Methods

This study retrospectively analyzed data from 61 patients with acute AC joint dislocation between July 2011 and November 2015. The patients were grouped according to surgical procedure: HP (n = 36) and TR (n = 25). Clinical outcomes at final follow-up were evaluated using the visual analog scale (VAS) for pain; the American Shoulder and Elbow Surgery score; the Korean Shoulder Score; and the University of California, Los Angeles (UCLA) shoulder score. Side-to-side coracoclavicular (CC) distance on radiographs, postoperative complications, and the rate of subacromial erosion in the HP group were also assessed between procedures.

Results

The mean follow-up period was 7.0 ± 1.0 years, and there were no significant differences in pain or outcome scores between the HP and TR groups (all P > .05). Forward flexion was better in the TR group (172.6° ± 5.6°) versus the HP group (166.0° ± 10.8°; P = .002). The percentages of patients with a difference in the side-to-side CC distance of <5 mm were 83.3% and 72.0% in the HP and TR groups, respectively (P = .288). Complications were found in 2 patients in the HP group and 1 in the TR group (P ≥ .999). Subacromial erosion was observed in 41.7% of patients after HP fixation, with no difference in VAS pain scores at the final follow-up in patients with versus without subacromial erosion (P = .719).

Conclusion

When comparing HP with TR fixation for the treatment of acute AC joint dislocations, there were no significant differences in functional outcome scores, final CC distance, or complications. Slightly better forward flexion was seen after TR fixation. Subacromial erosion occurred in 40% of patients after HP fixation, but this did not affect long-term VAS pain scores. Both surgical techniques are effective treatment options for AC joint dislocation.

Reliability of Upright Chest Radiography as a Diagnostic Screening Tool for Acromioclavicular Joint Dislocations

Background

The standard radiographic view for diagnosing acromioclavicular joint (ACJ) dislocations is the Zanca view of both shoulders to assess superior displacement of the distal clavicle by measuring the coracoclavicular distance (CCD) and comparing it with the uninjured shoulder; however, there is no consensus on a gold standard for diagnostic measures to classify acute ACJ injuries.

Purpose

To compare the CCD from an upright chest radiograph with a standard Zanca view of both shoulders in patients with an ACJ dislocation.

Study Design

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

Methods

We reviewed the records of 70 patients with an ACJ dislocation between 2010 and 2021 who had both an upright chest radiograph and a Zanca view. An ACJ dislocation was classified as low grade (Rockwood types 1-3) or high grade (Rockwood type 5). The CCD was measured on the upright chest radiograph and the Zanca view by 2 independent reviewers, and the percentage of the CCD difference compared with the unaffected side (ΔCCD) was calculated and compared between the upright chest radiograph and the Zanca view. Interrater and intrarater reliability were determined using the intraclass correlation coefficient.

Results

Included were 70 patients (55 male and 15 female; mean age, 46 years). There were 29 patients (41.43%) with a low-grade injury and 41 patients (58.57%) with a high-grade injury. In the overall analysis, the ΔCCD on the upright chest radiograph and Zanca view was significantly different (130.25% ± 88.42% vs 152.69% ± 106.56%, respectively; mean difference, 22.44% [95% CI, 2.40% to 42.48%]; P = .029). The subgroup analysis revealed that the ΔCCD on the upright chest radiograph and Zanca view was significantly different for patients with a low-grade injury (60.71% ± 25.79% vs 91.46% ± 68.54%, respectively; mean difference, 30.76% [95% CI, 7.18% to 54.33%]; P = .012) but not different for patients with a high-grade injury (179.45% ± 83.87% vs 196.00% ± 107.97%, respectively; mean difference, 16.56% [95% CI, -14.06% to 47.18%]; P = .281). The intraclass correlation coefficients for the ΔCCD measurements indicated good to excellent interrater and intrarater reliability.

Conclusion

The study findings indicated that upright chest radiography can be used as a diagnostic screening tool for high-grade ACJ dislocations, but not for low-grade ACJ injuries, compared with the Zanca view.

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.

Acromioclavicular and coracoclavicular ligamentous insertion distances depend on the scapular tilt and decrease with anterior direction of the inferior scapula angle

PURPOSE

A variety of reconstruction techniques exist for the operative treatment of a ruptured acromioclavicular and coracoclavicular ligamentous complex. However, the complication rate remains high; between 5 and 89%. The intraoperative distance between the clavicle, acromion and coracoid is important for the refixation quality. In this study, the influence of scapular deflection on coracoclavicular and acromioclavicular distances was analysed.

METHODS

The ligamentous insertions of 24 fresh-frozen human scapulae were exposed. The coracoclavicular and acromioclavicular ligaments were referenced and captured in a rigid body system using a three-dimensional (3D) measurement arm. The inferior angle of the scapula was manually pulled into maximum anterior and posterior deflection, simulating a patient positioning with or without dorsal scapular support, respectively. Based on the rigid body system, the distances between the ligamentous insertions were calculated. Statistical evaluation was performed by setting the distances in anterior deflection to 100% and considering the other distances relative to this position.

RESULTS

The scapular deflection had a considerable impact on the distance between the ligamentous insertions. Concerning the conoid ligament, the mean distance was almost doubled when the inferior angle pointed posteriorly compared to anterior deflection (195.3 vs 100.0%; p = 0.028). The insertion of the acromioclavicular capsule also showed a significant association with the direction of deflection (posterior = 116.1% vs. anterior = 100%; p = 0.008).

CONCLUSION

Dorsal support shifting the inferior angle of the scapula anteriorly reduces the distance between the ligamentous insertions. Therefore, a patient position on a shoulder table with posterior support of the scapula is recommended to reliability reduce the acromioclavicular joint.

Delayed acromioclavicular joint reconstruction using a modern suspensory device does not increase the risk of fixation failure or major complications

BACKGROUND

Management of displaced acromioclavicular joint (ACJ) injuries remains contentious. It is unclear if delayed vs. acute reconstruction has an increased risk of fixation failure and complications. The primary aim of this study was to compare complications of early vs. delayed reconstruction. The secondary aim was to determine modes of failure of ACJ reconstruction requiring revision surgery.

METHODS

A retrospective study was performed on all patients who underwent operative reconstruction of ACJ injuries over a 10-year period (Rockwood III-V) using suspensory devices with or without hamstring allograft. Reconstruction was classed as early (<12 weeks from injury) or delayed (≥12 weeks). Patient demographics, fixation method, and postoperative complications were noted, with 1-year follow-up a minimum requirement for inclusion. Patient-reported outcomes with the Disabilities of the Arm, Shoulder, and Hand score and EuroQol-5 Dimension were undertaken. Fixation failure was defined as loss of reduction requiring revision surgery.

RESULTS

A total of 104 patients were analyzed (n = 59 early and n = 45 delayed). The mean age was 42.0 (standard deviation: 11.2; 17-70 years); 84.6% were male and 15.4% were smokers. No difference was observed between fixation failure (P = .39) or deep infection (P = .13) with regard to acute vs. delayed reconstruction. No patient demographic or timing of surgery was predictive of fixation failure on regression modeling. Overall, 11 patients underwent revision surgery for loss of reduction and implant failure (n = 5 suture fatigue, n = 2 endobutton escape, n = 2 coracoid stress fracture, and n = 2 deep infection). The EuroQol-5 Dimension (P = .084) and Disabilities of the Arm, Shoulder, and Hand score (P = .062) were comparable for early and delayed groups respectively and below the minimal clinically important difference.

CONCLUSION

This study found that delayed surgical management of ACJ injuries using a modern device has comparable functional outcomes and is not associated with a higher incidence of fixation failure or major complications.

Bifocal Stabilisation of Acute Acromioclavicular Joint Dislocation using Suture Anchor and Temporary K-Wires: A Retrospective Analysis

Introduction

The acromioclavicular joint (ACJ) is a major link connecting the upper limb to the torso. The acromioclavicular and coracoclavicular (CC) ligaments help in stabilising the joint. We feel it is prudent to address both these ligament injuries, to achieve optimum result. This study was undertaken to analyse the results of a simple frugal surgical technique we used to deal with this injury considering stabilisation for both these ligaments.

Materials and methods

In this retrospective study, skeletally mature patients with Type III, IV or V ACJ dislocations who underwent open reduction and stabilisation of the joint with temporary K-wires, repair of the capsule and augmentation of CC ligaments with suture anchors were included. Clinico-radiological and functional outcome was evaluated. Functional assessment of the upper limb was analysed using the Disabilities of Arm, Shoulder, and Hand Score (DASH), Constant shoulder score (CSS) and Oxford shoulder score (OSS).

Results

Clinical and radiological evaluation of the 32 patients who had completed two years from the index surgery, was done. Out of the 37 patients included initially, five were lost in follow-up. Majority of the subjects included were males and type V was the most common injury. Mean pre-operative CC distance on the affected side was 13.92±4.94mm. In the immediate post-operative radiograph, it was 7.63±2.08mm and in the final follow- up was 9.36±2.75mm. Measurements were taken by two independent investigators and inter, and intra-observer reliability were analysed by Interclass correlation coefficient. Excellent functional outcome was noted despite the 1.81±1.50mm average loss of correction. At final follow-up, mean DASH score was 4.67±4.18, Oxford shoulder score was 44.06±2.44 and Constant shoulder score was 86.37±5.81. The severity of the injury had no significant effect on the functional outcome post our method of stabilisation and rehabilitation.

Conclusion

Bifocal fixation restores the multidirectional stability of the disrupted ACJ. Adequate radiological reduction, good functional outcome and simplicity of execution make this technique an undemanding one for use in regular practice.

Clavicular hook plate for acute high-grade acromioclavicular dislocation involving Rockwood type V: clinical and radiological outcomes and complications evaluation

Background

The surgical treatment of high-grade acromioclavicular joint dislocation remains a matter of debate. Clavicular hook plate internal fixation was widely used in the treatment of acromioclavicular dislocation because of its easy-to-master surgical technique. This study aimed to evaluate outcomes using hook plate fixation for acromioclavicular dislocation.

Methods

A consecutive series of 57 patients with acute acromioclavicular joint dislocation involving Rockwood type V were treated between November 2013 and September 2019 using hook plate fixation. The functional outcomes (using the visual analogue score, Constant-Murley score, and University of California Los Angeles score), the quality of surgical reduction (using the coracoclavicular distance), and post-operative complications were assessed with about 46 months of follow-up.

Results

The mean Constant-Murley score increased from 72.6 before surgery to 87.6 at final follow-up. The mean University of California Los Angeles score was 14.1 pre-operatively and 31.6 at final follow-up. Meanwhile, the visual analogue scores were significantly reduced from 3.4 pre-operatively to 1.3 post-operatively. The coracoclavicular distance decreased from 19.4 mm pre-operatively to 10.9 mm at the last follow-up. Post-operative functional and radiological outcomes were significantly improved compared with pre-operative outcomes (P < 0.01). The overall excellent and good result was 35.1% (20/57) and 54.1% (31/57), respectively. At follow-up, the overall complication rate was 15.8% (9/57) including subacromial impingement (three patients), acromial osteolysis (three patients), reduction loss (one patient), acromioclavicular joint osteoarthritis (one patient), and calcification (one patient).

Conclusion

Hook plate fixation was a viable treatment approach, and achieved good clinical outcomes in the treatment of acute acromioclavicular dislocation involving V. But some complications of hook plate fixation should not be ignored.

No difference in clinical outcome at 2-year follow-up in patients with type III and V acromioclavicular joint dislocation treated with hook plate or physiotherapy: a randomized controlled trial

BACKGROUND

The need for operative treatment of acute acromioclavicular (AC) joint dislocation is unclear. The purpose of this randomized controlled trial was to compare the outcomes after operative treatment with a hook plate with the outcomes after nonoperative treatment of acute Rockwood type III and type V AC joint dislocations separately.

METHODS

The inclusion criteria were patients aged 18-65 years with an acute type III or type V AC joint dislocation with the availability to start treatment within 3 weeks after trauma. All patients received the same standardized outpatient rehabilitation protocol and were followed up for 24 months. Assessments were based on radiographs, clinical examination findings, and questionnaires. The primary outcome was the Constant score (CS). The secondary outcomes were as follows: Subjective Shoulder Value (SSV), QuickDASH score (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire), shoulder pain at rest and during movement rated using a visual analog scale, EQ-5D (European Quality of Life 5 Dimensions) score, patient satisfaction, cosmesis, complications, and adverse events. The 4 groups were compared using 1-way analysis of variance and intention to treat.

RESULTS

The included patients (N = 124) (mean age, 40 years [range, 18-64 years]; 91% male patients) were randomized, stratified by type, to nonoperative treatment (type III, n = 33; type V, n = 30) or operative treatment with a hook plate (type III, n = 30; type V, n = 31) at a single center. Three patients randomized to physiotherapy dropped out before any follow-up measures, leaving 121 patients in the study. Complete clinical follow-up data were obtained from 118 patients at 24 months. At 3 months, patients in both nonoperatively treated groups had a significantly better mean CS, SSV, and QuickDASH score and had less pain at rest and during movement compared with patients treated operatively. At 6, 12, and 24 months, there were no significant differences in the CS, SSV, QuickDASH score, pain, or EQ-5D score between the groups regardless of intervention. At 24 months, the mean CS was 88 for nonoperatively treated type III patients vs. 91 for operatively treated type III patients and was 90 vs. 91 for type V patients (P = .477). At final follow-up, patients had regained 97% of the mean CS comparing the uninjured and injured shoulders and 86% of the patients rated the result as excellent or good. Eleven patients assigned to nonoperative treatment (18%, 6 type III and 5 type V) underwent surgery within 19 months.

CONCLUSIONS

Both the nonoperative and operative treatment groups had very good restoration of shoulder function and patient satisfaction at 24 months, and operative treatment did not lead to better outcomes compared with nonoperative treatment. In conclusion, our study does not support surgery with a hook plate in patients with acute Rockwood type III or type V AC joint dislocations.

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.

Surgery improves the clinical and radiological outcome in Rockwood type IV dislocations, whereas Rockwood type III dislocations benefit from conservative treatment

PURPOSE

Despite the available classifications, diagnostics and treatment of acute acromioclavicular joint (ACJ) injuries are still vague and challenging for trauma and shoulder surgeons. This study aimed to evaluate the dynamic radiographic as well as clinical outcome of operatively and conservatively treated Rockwood (RW) type III and IV ACJ dislocations.

MATERIALS AND METHODS

All patients with RW type III and IV ACJ dislocations between 2009 and 2016 (n = 226) were included in this retrospective data analysis with a prospective follow-up examination. According to their injury classification, patients were subdivided in an operative and conservative treatment group. Examiner blinded clinical evaluation including the constant score (CS), American shoulder and elbow surgery (ASES) score, the acromioclavicular joint instability (ACJI) score, visual analog scale (VAS), bilateral force measurements, and posttraumatic/postsurgical sequelae were assessed. Fluoroscopic evaluations including dynamic stability assessment with functional axillary views were performed for every patient.

RESULTS

For follow-up examination (mean 4.8 years ± 0.3 SEM) 56 patients (29 RW type III, 27 RW type IV) were available. In patients with RW type III ACJ dislocations [operative (n = 10); conservative (n = 19)] prolonged duration of treatment was seen in operatively treated patients (p < 0.05). Clear improvement could be shown for the ACJI score (p < 0.05) and coracoclavicular (CC) and acromioclavicular (AC) distance (p < 0.05) in the operative group. In patients with RW type IV ACJ dislocations [operative (n = 18); conservative (n = 9)] superior clinical results were found in operated patients with highly significant differences for the ACJI score (p < 0.001). Radiographic dynamic horizontal analysis showed nearly normalized anteroposterior translation in operated patients (p < 0.05). No differences were found regarding arthroscopic or open procedures.

CONCLUSION

Accurate diagnostics including sufficient dynamic stability assessment with functional axillary views are strongly advised for patients with ACJ dislocations. Conservative treatment should be recommended for patients with RW type III ACJ dislocations, due to shorter duration of treatment with good clinical results but lacking operative risks. In patients with RW type IV ACJ dislocations, surgical treatment is recommended because of superior clinical and radiological results.

LEVEL OF EVIDENCE

Level III.

Anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon allograft is effective for chronic acromioclavicular joint injuries at mid-term follow-up

PURPOSE

To evaluate the clinical and radiographic outcomes of patients undergoing anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon allografts for the treatment of chronic acromioclavicular joint (ACJ) injuries with a minimum 1-year follow-up.

METHODS

Patients who underwent ACCR for chronic ACJ injuries between 2003 and 2017 were analyzed. Clinical outcome measures included American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CM), Simple Shoulder Test (SST), and Single Assessment Numerical Evaluation (SANE) scores. Radiographic loss of reduction during follow-up was evaluated by calculating the difference (mm) in the coracoclavicular distance (CCD) of the involved side immediately postoperatively and at terminal follow-up.

RESULTS

Forty-two patients (mean age: 42.7 ± 12.8 years) were included in the study with an average follow-up of 3.8 ± 3.1 years (range: 1.1-11.5 years). Patients achieved significant improvement in ASES (50.2 ± 20.1 pre to 85.2 ± 16.3 post), CM (60.2 ± 18.5 pre to 88.2 ± 9.1 post), SST (6.1 ± 3.2 pre to 9.5 ± 3.7 post), and SANE (24.0 ± 25.7 pre to 89.0 ± 12.7 post) scores (P < 0.001, respectively). There were no significant differences in functional improvement when comparing type III and V injuries (n.s.). Mean increase in CCD of the involved side from immediately postoperative to final radiographic follow-up was 4.1 ± 3.9 mm, with no significant correlation to clinical outcomes scores. Complications occurred in 33.3% of cases, with postoperative heterotopic ossification being most frequent (14.3%).

CONCLUSION

Patients undergoing ACCR using free tendon allografts for chronic ACJ injuries achieved significant improvement in shoulder function at a mean follow-up of 3.8 years. No correlation was observed between the amount of loss of reduction and clinical outcome scores. Free tendon allografts may be a reliable alternative to autografts in the treatment of chronic ACJ dislocations.

LEVEL OF EVIDENCE

IV.

Ligamentous and capsular restraints to anterior-posterior and superior-inferior laxity of the acromioclavicular joint: a biomechanical study

BACKGROUND

Approximately 9% of shoulder girdle injuries involve the acromioclavicular joint (ACJ). There is no clear gold standard or consensus on surgical management of these injuries, in part perpetuated by our incomplete understanding of native ACJ biomechanics. We have therefore conducted a biomechanical study to assess the stabilizing structures of the ACJ in superior-inferior (SI) translation and anterior-posterior (AP) translation.

METHODS

Twenty fresh frozen cadaveric specimens were prepared and mounted onto a robotic arm. The intact native joint was tested in SI translation and AP translation under a 50-N displacing force. Each specimen was retested after sectioning of its stabilizing structures in the following order: investing fascia, ACJ capsular ligaments, trapezoid ligament, and conoid ligament. Their contributions to resisting ACJ displacements were calculated.

RESULTS

In the intact native ACJ, mean anterior displacement of the clavicle was 7.9 ± 4.3 mm, mean posterior displacement was 7.2 ± 2.6 mm, mean superior displacement was 5.8 ± 3.0 mm, and mean inferior displacement was 3.6 ± 2.6 mm. The conoid ligament was the primary stabilizer of superior displacement (45.6%). The ACJ capsular ligament was the primary stabilizer of inferior displacement (33.8%). The capsular ligament and conoid ligament contributed equally to anterior stability, with rates of 23% and 25.2%, respectively. The capsular ligament was the primary contributor to posterior stability (38.4%).

CONCLUSION

The conoid ligament is the primary stabilizer of superior displacement of the clavicle at the ACJ and contributes significantly to AP stability. Consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries.

Nonanatomic and Suture-Based Coracoclavicular Joint Stabilization Techniques Provide Adequate Stability at a Lower Cost of Implants in Biomechanical Studies When Compared With Anatomic Techniques: A Systematic Review and Meta-Analysis

Purpose

To compare the stability and cost of the used implants in nonanatomic and anatomic acromioclavicular joint repair/reconstruction (ACCR) techniques tested in cadaveric shoulder biomechanical studies during the last decade.

Methods

A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and prospectively registered in PROSPERO. Two independent reviewers searched PubMed, Embase, and Virtual Health Library databases. Studies evaluating 3-direction stability under 70-N loads and load-to-failure protocols with servohydraulic testing systems were included. A meta-analysis of the mean differences of anterior, posterior, and superior direction; relative stability value in 3 directions; superior direction load-to-failure; stability/cost index; and load-to-failure/cost index was performed using a continuous random-effects model and 95% confidence interval.

Results

Eighteen articles were included. Both non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and load-to-failure. ACCR techniques were biomechanically better in terms of anterior stability (P = .04) and relative stability value (mean difference 64.08%, P = .015). However, supraphysiological stability and failure loads were achieved with non-ACCR techniques at a lower cost of implants. Techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes had the greatest stability/cost index and load-to-failure/cost index among the included techniques (confidence interval 99%).

Conclusions

Non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and failure loads in controlled biomechanical testing. However, non-ACCR and techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes provide supraphysiologic stability and failure loads at a lower cost of implants.

Clinical Relevance

Non-ACCR and suture-based techniques may provide more cost-effective and greater value treatment for acromioclavicular joint injury and could be considered in the surgical management of normal activity individuals and cost-sensitive populations.

Treatment of a Failed Type V Acromioclavicular Separation Due to Coracoid Fracture: Revision of Acromioclavicular-Coracoclavicular Reconstruction and Coracoid Fixation

Acromioclavicular (AC) injuries are common, especially in the young and active population. AC joint dislocations account for 8% of all joint dislocations and are even more common in contact sports. These injuries are graded as type I through type VI on the basis of the Rockwood classification method. Types I and II are generally treated without surgery whereas types IV, V, and VI are best treated operatively. Type III dislocations remain controversial in terms of treatment, and many surgeons recommend nonoperative treatment first and operative treatment in case of continued symptoms such as pain, instability, or shoulder girdle dysfunction. The goal of operative treatment is to restore AC joint stability, which involves addressing both the coracoclavicular and coracoacromial ligaments to achieve a desirable patient outcome. The objective of this Technical Note is to describe our technique for management of a failed acromioclavicular stabilization, treated with a coracoclavicular and AC joint capsular reconstruction using tibialis anterior and semitendinosus allografts.

Acromioclavicular joint reconstruction implants have differing ability to restore horizontal and vertical plane stability

PURPOSE

Persistent acromioclavicular joint (ACJ) instability following high grade injuries causes significant symptoms. The importance of horizontal plane stability is increasingly recognised. There is little evidence of the ability of current implant methods to restore native ACJ stability in the vertical and horizontal planes. The purpose of this work was to measure the ability of three implant reconstructions to restore native ACJ stability.

METHODS

Three groups of nine fresh-frozen shoulders each were mounted into a robotic testing system. The scapula was stationary and the robot displaced the clavicle to measure native anterior, posterior, superior and inferior (A, P, S, I) stability at 50 N force. The ACJ capsule, conoid and trapezoid ligaments were transected and the ACJ was reconstructed using one of three commercially available systems. Two systems (tape loop + screw and tape loop + button) wrapped a tape around the clavicle and coracoid, the third system (sutures + buttons) passed directly through tunnels in the clavicle and coracoid. The stabilities were remeasured. The data for A, P, S, I stability and ranges of A-P and S-I stability were analyzed by ANOVA and repeated-measures Student t tests with Bonferroni correction, to contrast each reconstruction stability versus the native ACJ data for that set of nine specimens, and examined contrasts among the reconstructions.

RESULTS

All three reconstructions restored the range of A-P stability to that of the native ACJ. However, the coracoid loop devices shifted the clavicle anteriorly. For S-I stability, only the sutures + buttons reconstruction did not differ significantly from native ligament restraint.

CONCLUSIONS

Only the sutures + buttons reconstruction, that passed directly through tunnels in the clavicle and coracoid, restored all stability measures (A, P, S, I) to the native values, while the tape implants wrapped around the bones anteriorised the clavicle. These findings show differing abilities among reconstructions to restore native stability in horizontal and vertical planes. (300 words).

High degree of consensus achieved regarding diagnosis and treatment of acromioclavicular joint instability among ESA-ESSKA members

PURPOSE

To develop a consensus on diagnosis and treatment of acromioclavicular joint instability.

METHODS

A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when ≥ 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data.

RESULTS

A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similar CONCLUSION: A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified.

LEVEL OF EVIDENCE

Level V.

All-Endoscopic Treatment of Acromioclavicular Joint Dislocation: Coracoclavicular Ligament Suture and Acromioclavicular Ligament Desincarceration

Acute acromioclavicular (AC) joint dislocations are common and difficult to manage. The physiopathologic pattern begins with the rupture of the AC ligaments, then the coracoclavicular (CC) ligaments, and with an invasion of the clavicle through the deltotrapezial fascia. Therefore, we tend to perform a true suture of the CC ligaments, along with a release of the AC ligaments from the joint. We thus propose an all-endoscopic CC ligament suture and AC joint release. It starts with glenohumeral exploration enabling a repair of concomitant lesions when necessary. Dissection of the coracoid process is made, along with the lateral border of the conjoint tendon, medially the pectoralis minor tenotomy, and plexus brachial exposition and protection. Superiorly the CC ligaments are tagged and exposed. A major difference with others procedure then arises. We dissect the inferior and superior surfaces of the clavicle and the AC joint, although we maintain the continuity between the deltotrapezoid fascia and the AC ligaments. The AC dislocation is reduced under endoscopic control performing a true suture of the CC ligaments by the mean of 2 suture tapes and dog bones. After surgery, a shoulder brace is used for 6 weeks. Physiotherapy then begins.

Review of Weaver and Dunn on treatment of acromioclavicular injuries, especially complete acromioclavicular separation

This classic discusses the original publication "Treatment of acromioclavicular injuries, especially complete acromioclavicular separation" by Weaver and Dunn, which collaborated to develop a technique for acromioclavicular joint reconstruction in 1972. Their surgical technique described resection of 2 cm of the distal clavicle and transfer of the acromial end of the coracoacromial ligament into the medullary canal of the distal clavicle. (modified) Weaver-Dunn procedures have been regarded as one of the most effective techniques to treat complete acromioclavicular joint dislocation for a long time. However, anatomic reconstructions have taken over this position since recent biomechanical studies have demonstrated superior results. Although the Weaver-Dunn procedure has fallen out of favour, it remains of historical significance. For this reason, this review will comprise the historical overview of the Weaver-Dunn procedure, the men behind the eponym and the clinical implication then and now.

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.

Surgical techniques for management of acromioclavicular joint separations: review and update for radiologists

Imaging plays a central role in the postoperative management of acromioclavicular (AC) joint separations. There are more than 150 described techniques for the surgical management of AC joint injuries. These procedures can be categorized as varying combinations of the following basic techniques: a) soft-tissue repair, b) trans-articular AC joint fixation, c) coracoclavicular (CC) fixation, d) non-anatomic reconstruction of the CC ligaments, e) anatomic reconstruction of the CC ligaments, f) distal clavicle resection, and g) dynamic muscle transfer. The goals of this article are to describe the basic techniques for the surgical management of AC joint separations with an emphasis on technique-specific complications and postoperative imaging assessment.

Open Acromioclavicular Joint Reconstruction With Semitendinosus Allograft Utilizing the Cerclage Technique

Acromioclavicular (AC) joint injuries most commonly occur in young males after a direct injury at the acromion. General consensus stresses nonoperative treatment for type I and II injuries and surgical treatment for types IV through VI, whereas management of type III injuries is more controversial. If surgery is indicated, there are multiple techniques including hook plate, screw fixation, coracoclavicular fixation, and anatomic and nonanatomic reconstruction. The overall complication rate is high (14%), regardless of technique. In this Technical Note, we outline a technique for open repair of a chronic AC joint separation using a semitendinosus allograft using the cerclage for enhanced fixation.

Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults

BACKGROUND

Dislocation of the acromioclavicular joint is one of the most common shoulder injuries in a sport-active population. The question of whether surgery should be used remains controversial. This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To assess the effects (benefits and harms) of surgical versus conservative (non-surgical) interventions for treating acromioclavicular dislocations in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to June 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 6), MEDLINE (1946 to June 2019), Embase (1980 to June 2019), and LILACS (1982 to June 2019), trial registries, and reference lists of articles. There were no restrictions based on language or publication status.

SELECTION CRITERIA

We included all randomised and quasi-randomised trials that compared surgical with conservative treatment of acromioclavicular dislocation in adults.

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study screening and selection, 'Risk of bias' assessment, and data extraction. We pooled data where appropriate and used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included five randomised trials and one quasi-randomised trial. The included trials involved 357 mainly young adults, the majority of whom were male, with acute acromioclavicular dislocation. The strength of the findings in all studies was limited due to design features, invariably lack of blinding, that carry a high risk of bias. Fixation of the acromioclavicular joint using hook plates, tunnelled suspension devices, coracoclavicular screws, acromioclavicular pins, or (usually threaded) wires was compared with supporting the arm in a sling or similar device. After surgery, the arm was also supported in a sling or similar device in all trials. Where described in the trials, both groups had exercise-based rehabilitation. We downgraded the evidence for all outcomes at least two levels, invariably for serious risk of bias and serious imprecision.Low-quality evidence from two studies showed no evidence of a difference between groups in shoulder function at one year, assessed using the Disability of the Arm, Shoulder, and Hand questionnaire (DASH) (0 (best function) to 100 (worst function)): mean difference (MD) 0.73 points, 95% confidence interval (CI) -2.70 to 4.16; 112 participants. These results were consistent with other measures of function at one-year or longer follow-up, including non-validated outcome scores reported by three studies. There is low-quality evidence that function at six weeks may be better after conservative treatment, indicating an earlier recovery. Very low-quality evidence from one trial found no difference between groups in participants reporting pain at one year: risk ratio (RR) 1.32, 95% CI 0.54 to 3.19; 79 participants. There is very low-quality evidence that surgery may not reduce the risk of treatment failure, usually resulting in non-routine secondary surgery: 14/168 versus 15/174; RR 0.99, 95% CI 0.51 to 1.94; 342 participants, 6 studies. The main source of treatment failure was complications related to surgical implants in the surgery group and persistent symptoms, mainly discomfort, due to the acromioclavicular dislocation in the conservatively treated group.There is low-quality evidence from two studies that there may be little or no difference between groups in the return to former activities (sports or work) at one year: 57/67 versus 62/70; RR 0.96, 95% CI 0.85 to 1.10; 137 participants, 2 studies. Low-quality but consistent evidence from four studies indicated an earlier recovery in conservatively treated participants compared with those treated with surgery. There is low-quality evidence of no clinically important difference between groups at one year in quality of life scores, measured using the 36-item or 12-item Short Form Health Survey (SF-36 or SF-12) (0-to-100 scale, where 100 is best score), in either the physical component (MD -0.63, 95% CI -2.63 to 1.37; 122 participants, 2 studies) or mental component (MD 0.47 points, 95% CI -1.51 to 2.44; 122 participants). There is very low-quality and clinically heterogenous evidence of a greater risk of an adverse event after surgery: 45/168 versus 16/174; RR 2.82, 95% CI 1.65 to 4.82; 342 participants, 6 studies; I² = 48%. Common adverse outcomes were hardware complications or discomfort (18.5%) and infection (8.7%) in the surgery group and persistent symptoms (7.1%), mainly discomfort, in the conservatively treated group. The majority of surgical complications occurred in older studies testing now-outdated devices known for their high risk of complications. The very low-quality evidence from one study (70 participants) means that we are uncertain whether there is a between-group difference in patient dissatisfaction with cosmetic results.It is notable that the evidence for function, return to former activities, and quality of life came from the two most recently conducted studies, which tested currently used devices and interventions in clearly defined participant populations that represented the commonly perceived population for which there is uncertainty over the use of surgery. There were insufficient data to conduct subgroup analysis relating to type of injury and whether surgery involved ligament reconstruction or not.

AUTHORS' CONCLUSIONS

There is low-quality evidence that surgical treatment has no additional benefits in terms of function, return to former activities, and quality of life at one year compared with conservative treatment. There is, however, low-quality evidence that people treated conservatively had improved function at six weeks compared with surgical management. There is very low-quality evidence of little difference between the two treatments in pain at one year, treatment failure usually resulting in secondary surgery, or patient satisfaction with cosmetic result. Although surgery may result in more people sustaining adverse events, this varied between the trials, being more common in techniques such as K-wire fixation that are rarely used today. There remains a need to consider the balance of risks between the individual outcomes: for example, surgical adverse events, including wound infection or dehiscence and hardware complication, against risk of adverse events that may be more commonly associated with conservative treatment such as persistent symptoms or discomfort, or both.There is a need for sufficiently powered, good-quality, well-reported randomised trials of currently used surgical interventions versus conservative treatment for well-defined injuries.