Functional outcome of open acromioclavicular joint stabilization for instability following distal clavicle resection

Iatrogenic Excessive Clavicle Resection as a Complication of Arthroscopic Distal Clavicle Excision

Arthroscopic distal clavicle excision (DCE) is a reliable procedure to treat acromioclavicular joint arthritis. Typically, only 1 to 2 cm of distal clavicle should be removed. Resection of too much bone can lead to instability of the joint or lack of support to the shoulder. We describe 2 patients who had excessive clavicular bone removed arthroscopically, leading to irreparable clavicular pain and dysfunction. The 2 female patients, ages 56 and 60 years, presented to our clinic with continued pain after DCE. Both had pain intractable with nonoperative treatment and loss of range of motion of the shoulder. Radiographs revealed a distal clavicle defect of 7.5 cm in 1 patient. The second patient had a 2-cm distal clavicular defect with an adjacent 2-cm clavicle bone fragment between the defect and residual clavicle shaft. Both underwent surgery with subtotal claviculectomy for pain control. During surgery, 1 patient had a subclavian vein requiring vascular repair. After 1 year of follow-up, both patients had reduced but residual pain and restricted range of motion. Only 1 patient could rejoin her preinjury occupation. Neither patient could continue with preinjury recreational sports. Excessive removal of the distal clavicle during DCE can result in continued pain and disability of the shoulder. Methods to visualize the anatomy of the distal clavicle and its articulation to the acromion should be considered when performing this operation arthroscopically. Reoperation to remove subtotal clavicle has good clinical outcomes but may lead to serious complications due to the proximity to major neurovascular structures. [Orthopedics. 2024;47(1):e57-e60.].

Acromioclavicular joint injuries revisited: Pathoanatomy, pathomechanics, and clinical presentation

Multiple papers have described aspects of treatment of acromioclavicular (AC) joint injuries. Most have emphasized aspects of surgical treatment, and some papers have addressed non-operative treatment. Few papers have highlighted the specific pathoanatomy of an AC joint injury or have described methods of evaluating the 3-dimensional pathomechanics resulting from the pathoanatomical injury. This paper is based on 3 observations: (1) AC joint injuries exist and present on a spectrum of pathoanatomy; (2) The effect of the pathoanatomy on normal AC joint mechanics to produce pathomechanics is dependent on the extent of the pathoanatomy; and (3) Treatment protocols should be developed to address the specific pathoanatomy to optimize the mechanics. A comprehensive clinical approach emphasizing the evaluation of the extent of the anatomic injury and understanding its mechanical consequences regarding shoulder and arm function is a key in the development of guidelines for developing operative or non-operative treatment protocols and for establishing outcomes of the treatment protocols.

Nonoperative Management of Traumatic Acromioclavicular Joint Injury: A Clinical Commentary with Clinical Practice Considerations

Traumatic injuries of the acromioclavicular joint result in pain and potentially long-term alterations in scapulohumeral rhythm that occurs due to disruption of the clavicular strut function which is integral to scapular kinematics. Nonoperative treatment remains a valid option in most acromioclavicular joint injuries with the potential of minimizing pain and restoring scapulohumeral rhythm. However, few studies have provided nonoperative treatment details. Therefore, the purpose of this clinical commentary is to discuss the rationale, indications, and techniques of nonoperative treatment and present an organized approach for evaluating and managing such patients based on the best available evidence. Attention will be focused on identifying the treatment methods employed and the results/outcomes of such treatments.

Level of Evidence

5.

New possibilities: the LockDown device for distal clavicle fractures

Background and hypothesis

The majority of distal clavicle fractures are displaced fractures and constitute a treatment challenge because they have a 30% chance of delayed union or nonunion. Although several options for surgical reconstruction have been described, in patients with a comminuted and/or small distal fragment, these reconstructive options have proved to be prone to failure. Moreover, secondary surgery for removal is necessary in most cases. We hypothesized that the LockDown device, a braided synthetic ligament device, combined with resection of the distal fracture fragment is a suitable alternative in specified patients with distal clavicle fractures.

Methods

Eleven patients with distal clavicle fractures were treated with distal fracture resection and the LockDown procedure. All patients underwent regular follow-up with data collection; additionally, 7 were assessed at 1-year follow-up according to the study protocol. On the basis of radiography, these patients had a clear coracoclavicular ligament disruption and subsequent cranial dislocation of the medial fragment. Regular follow-up was performed at 6 weeks, 3 months, and 6 months. Control radiographs were taken at 3 and 6 months. Furthermore, the 7 enrolled patients were assessed at 1 year, when the Disabilities of the Arm, Shoulder and Hand score, Constant shoulder score, Nottingham Clavicle Score, and range of motion were recorded. Residual pain was ascertained by a visual analog scale score.

Results

In total, 11 patients were treated with distal clavicle resection and the LockDown procedure. Eight patients underwent surgery within 3 weeks after presentation at the emergency department. The other 3 patients were operated on after a trial of conservative treatment (due to persisting pain and delayed union). None of the patients had postoperative complications. At 3 months, 9 of the 11 patients had made a full recovery.

Discussion

All 11 patients had good short-term clinical outcomes. None showed acromioclavicular instability. Furthermore, secondary surgery was avoided, and hardware complications did not occur. In low-demand patients or patients with a high risk of nonunion, this technique may be a favorable alternative to other known techniques.

Surgical treatment of acute and chronic AC joint dislocations: Five-year experience with conventional and modified LARS fixation by a single surgeon

BACKGROUND

Different surgical fixation methods are available for the treatment of acromioclavicular (AC) joint dislocations. The aim of this study was to present the results of five years of experience with the Ligament Augmentation and Reconstruction System (LARS) fixation technique by a single surgeon.

METHODS

A single-center retrospective cohort study was performed. All patients treated for an AC joint dislocation with LARS fixation by the same surgeon between 2012 and 2016 (n = 20) were eligible for inclusion. All these dislocations were unstable injuries, Rockwood type-III or higher, requiring acute or chronic repair. The primary outcome was the QuickDASH score. Secondary outcomes were the Subjective Shoulder Value (SSV), Numerical Rating Scale (NRS) pain score, return to work, complications, and implant removal.

RESULTS

17 patients (85%) were available for final follow-up. The median follow-up was 23 months (IQR; 17─34). The median QuickDASH score was 7 (IQR; 2-18), the median SSV was 90 (IQR; 80-90), and the median NRS pain score was 2 (IQR; 1-3). Patients returned to work after a median of 8 weeks (IQR; 6-12). There was no significant difference in functional outcome scores between acute and chronic repair, or between the conventional and modified LARS fixation groups. There were two major complications requiring revision surgery, one ruptured LARS ligament and one case of deep wound infection. Implant removal was performed in one patient.

CONCLUSIONS

The LARS ligament fixation technique seems to be effective for the treatment of AC joint dislocations, resulting in good short- and mid-term patient-reported functional outcome. LARS fixation might also be an acceptable treatment option for active patients with symptomatic chronic AC dislocations.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study, Treatment Study.