Palmaris longus tendon graft versus modified Weaver-Dunn procedure via dynamic button system for acromioclavicular joint reconstruction in chronic cases

Modified Weaver Dunn Versus Ligamentous Reconstruction Grafts in Chronic Acromioclavicular Joint Dislocation: A Systematic Review and Meta-Analysis of Comparative Studies

Background

Acromioclavicular (AC) joint trauma is a frequent sports injury. Modified Weaver Dunn (MWD) is a commonly used technique to address this injury. However, tendinous grafts (Autogenous Palmaris Longus or Semitendinosus tendons) are increasingly being used due to the biologic weakness of MWD.

Methods

Three search was done until January 2024 with data extraction consisting of adverse events (infections and failures), Constant-Murley score, American Shoulder and Elbow Surgeons score, and postoperative coracoclavicular distance.

Results

Four studies were included in this metaanalysis. Tendinous graft was shown to have statistically better ASES and Constant-Murley scores. Furthermore, there were no difference in adverse events, and postoperative coracoclavicular distance.

Conclusion

The tendinous graft showed no differences in adverse events, and postoperative coracoclavicular distance when compared to modified Weaver Dunn. However, it showed higher postoperative ASES and Constant-Murley score without analysis of the minimal clinical important difference making the difference solely statistical.

Level of evidence

3.

Reconstruction of Coracoclavicular Ligaments with Semitendinosus Autograft and Temporary Kirschner Wires is a good option for Chronic Acromioclavicular Joint Instability

Introduction

This study reports the results of surgical anatomic reconstruction of torn coracoclavicular ligaments with an autogenous semitendinosus graft and temporary Kirschner wires (K-wires) in chronic acromioclavicular (AC) joint dislocations.

Materials and methods

Nineteen shoulders underwent surgical anatomic reconstruction of torn coracoclavicular (CC) ligaments with an autogenous semitendinosus tendon graft and temporary K-wires for Rockwood grade III, IV and V chronic AC joint dislocations. Pre-operative data included patients' demographic characteristics, injury characteristics and surgical histories. The primary outcome measures were the University of California Los Angeles (UCLA) shoulder rating scale and visual analogue pain scoring (VAS), and the complications were noted for each patient.

Results

Surgical anatomic reconstruction of torn CC ligaments was performed in 19 patients with a mean age of 41.6±16 years (range 21-72 years). All of the patients were satisfied and felt better after CC ligament reconstruction. The average UCLA shoulder rating scale score was good/excellent: 29.4 (range 23-34) out of 35 points. The average pre-operative VAS score was 7.7 points out of 10 and improved to 1.1 points post-operatively (p<0.05). None of the patients experienced failure during the follow-up. One patient had a mild subluxation, but the patient was satisfied with the result.

Conclusions

This technique is simple, reliable, and biologic without major complications. It is also a cost-effective procedure since it can be performed with Kirschner wires and autogenous grafts. It has a major advantage of leaving no implants inside the joint, which can lead to hardware complications, and it can be performed in basic operating room settings.

Anatomical acromioclavicular joint stabilization with chemically sterilized tendon allografts: A retrospective study

Background

The purpose of this retrospective study was to analyze whether chemically sterilized tendon allografts perform as well as other non-sterilized allografts and autografts as described in the literature for anatomical acromioclavicular joint stabilization for the treatment of Rockwood III-V. Allografts are still described as a factor for higher re-rupture rates.

Methods

Retrospective data were collected from 21 acromioclavicular joint stabilizations performed by a single surgeon and performed between 2011 and 2014 using sterilized semitendinosus allografts. The primary endpoints were re-rupture and complication rates. Secondary endpoints were AC-joint stability, pain level, return to work and sport and the range of motion.

Results

No re-ruptures occurred during the mean follow-up time of 33 months. Zero complications occurred directly after surgery, but three complications later than three weeks after surgery. All cases resolved without further surgery. After surgery, stability significantly improved for all patients. Post-surgery, 19 patients had stable acromioclavicular joints and only two patients showed minor instabilities. Range of motion returned to the range of the healthy shoulders for all patients.

Conclusion

Chemically sterilized semitendinosus allograft use for anatomic AC-joint stabilization is equivalent to the use of other allografts or autografts and required no hardware removal. No donor age or graft size dependence was observed, due to zero re-ruptures.

A new diagnostic morphological parameter for the Carpal tunnel syndrome: The palmaris longus tendon cross-sectional area

Carpal tunnel syndrome (CTS) is correlated with increased intracarpal canal pressure (ICP). The effect of palmaris longus tendon (PLT) loading on ICP is documented in previous researches. PLT loading induces the greatest absolute increase in ICP. Therefore, to analyze the connection between the PLT and CTS, we newly made the measurement of the PLT cross-sectional area (PLTCSA). We assumed that PLTCSA is a reliable diagnostic parameter in the CTS. PLTCSA measurement data were acquired from 21 patients with CTS, and from 21 normal subjects who underwent wrist magnetic resonance imaging (W-MRI). We measured the PLTCSA at the level of pisiform on W-MRI. The PLTCSA was measured on the outlining of PLT. The two different cutoff values in the analysis were determined using receiver operating characteristic (ROC) analysis. The mean PLTCSA was 2.34 ± 0.82 mm2 in the normal group and 3.97 ± 1.18 mm2 in the CTS group. ROC curve analysis concluded that the best cutoff point for the PLTCSA was 2.81 mm2, with 76.2% sensitivity, 71.4% specificity, and area under the curve of 0.88 (95% CI, 0.78-0.98). PLTCSA is a sensitive, new, objective morphological parameter for evaluating CTS.

Surgical treatments for acute unstable acromioclavicular joint dislocations

INTRODUCTION

Surgical treatment is usually recommended for acute, high-grade acromioclavicular joint (ACJ) injuries. A wide variety of surgical techniques exist, and the literature does not strongly support one over the other. In this literature review, we describe and compare the results of different surgical treatments for the management of acute unstable ACJ dislocation and aim to guide surgeons on optimal treatment.

MATERIALS AND METHODS

A literature review was performed by searching PubMed, Medline, Cochrane, and Embase databases. Seventeen studies met the inclusion criteria and were analyzed. Only studies with comparative data were included. The clinical and radiological outcomes of these studies were reviewed.

RESULTS

Seventeen studies were included in this literature review. We found no difference in outcomes between open and arthroscopic procedures. Coracoclavicular ligament (CCL) reconstruction techniques provide better results than the more rigid hook plate fixation. There is no evidence that biologic repair with tendon graft is superior to synthetic grafts. Furthermore, an autograft is not shown to be better than an allograft. Rigid fixation between the clavicle and coracoid and the non-anatomic Weaver-Dunn technique appears less popular in recent literature. The hook plate is associated with subacromial osteolysis, acromial erosion, and the morbidity of a secondary procedure.

DISCUSSION

There is a recent increase in publications on the reconstruction of the ACJ after injury, with new techniques focusing on the anatomic reconstruction of the CCLs aiming to restore both vertical and horizontal plane stability of the ACJ using synthetic/biological grafts. Despite the plethora of new techniques introduced, meaningful comparisons are difficult to draw due to the heterogeneity of the treatments used and the outcome measure used to assess the results.

Hybrid coracoclavicular and acromioclavicular reconstruction in chronic acromioclavicular joint dislocations yields good functional and radiographic results

PURPOSE

Optimal treatment of chronic unstable acromioclavicular (AC) joint dislocations (stage 3-5 according the Rockwood classification) is still debated. Anatomic coracoclavicular (CC) reconstruction is a reliable option in terms of two-dimensional radiographic reduction, clinical outcomes, and return to sports, but there remain concerns regarding anterior-posterior stability of the AC joint with CC ligament reconstruction alone. The aim of the present study was to describe the mid-term results of a new hybrid technique with CC and AC ligament reconstruction for chronic AC joint dislocations.

METHODS

Twenty-two patients surgically treated for chronic AC joint dislocations (grade 3 to 5) were retrospectively reviewed. All patients were assessed before surgery and at final follow-up with the Constant-Murley score (CMS) and the American Shoulder and Elbow Surgeons (ASES) score. The CC vertical distance (CCD) and the CCD ratio (affected side compared to unaffected side) were measured on Zanca radiographs preoperatively, at 6 months postop and at final follow-up. The same surgical technique consisting in a primary fixation with a suspensory system, coracoclavicular ligaments reconstruction with a double loop of autologous gracilis and acromioclavicular ligaments reconstruction with autologous coracoacromial ligament was performed in all cases.

RESULTS

Twenty-two shoulders in 22 patients (19 males and 3 females) were evaluated with a mean age of 34.4 ± 9 years at the time of surgery. The mean interval between the injury and surgery was 53.4 ± 36.7 days. The mean duration of postoperative follow-up was 49.9 ± 11.8 months. According to the Rockwood classification, there were 5 (22.6%) type-III and 17 (77.2%) type-V dislocations. Mean preoperative ASES and CMS were 54.4 ± 7.6 and 64.6 ± 7.2, respectively. They improved to 91.8 ± 2.3 (p = 0.0001) and 95.2 ± 3.1 (p = 0.0001), respectively at final FU. The mean preoperative CCD was 22.4 ± 3.2 mm while the mean CCD ratio was 2.1 ± 0.1. At final FU, the mean CCD was 11.9 ± 1.4 mm (p = 0.002) and the mean CCD ratio was 1.1 ± 0.1 (p = 0.009). No recurrence of instability was observed. One patient developed a local infection and four patients referred some shoulder discomfort. Heterotopic ossifications were observed in three patients.

CONCLUSIONS

The optimal treatment of chronic high-grade AC joint dislocations requires superior-inferior and anterior-posterior stability to ensure good clinical outcomes and return to overhead activities or sports. The present hybrid technique of AC and CC ligaments reconstruction showed good clinical and radiographic results and is a reliable an alternative to other reported techniques.

LEVEL OF EVIDENCE

Level IV.

Criteria for return to play after operative management of acromioclavicular joint separation: a systematic review

Background

Acromioclavicular (AC) joint separation is a common cause of shoulder injury among athletes. High-grade injuries may require operative fixation, and comprehensive return-to-play guidelines have not yet been established. The purpose of this study was to summarize criteria for return to play after operative management of AC joint separation.

Methods

A systematic review of the literature was performed from January 1999 to April 2020 to evaluate clinical evidence regarding criteria for return to play after operative management of isolated AC joint separation.

Results

Sixty-three studies with at least 1 explicitly stated return-to-play criterion were identified out of an initial database search of 1253 published articles. Eight separate categories of return-to-play criteria were identified, the most common of which was time from surgery (95.2%). Return-to-play timelines ranged from 2 to 12 months, the most common timeline being 6 months (37.8%). Only 4 (6.3%) studies used conditional criteria to guide return to play, which included range of motion, strength, clinical stability, radiographic stability, functional assessment, safety assessment, and hardware removal.

Conclusion

Most published studies use only time-based criteria for return to play after surgery for AC joint separation, and only a small number of studies use additional subjective or objective criteria. While this systematic review helps provide a foundation for developing a comprehensive return-to-play checklist, further investigation is needed to establish safe and effective guidelines that will enable athletes to safely return to sport and minimize the recurrence of injury.

Does Weaver-Dunn procedure have a role in chronic acromioclavicular dislocations? A meta-analysis

Background

In treatment of chronic acromioclavicular (AC) joint dislocations, both the Weaver–Dunn procedure (WD) and CC ligament reconstruction (CCR) are recommended options due to the low possibility of healing of the coracoclavicular (CC) ligaments. The aim of this review was to determine whether CCR will yield favorable clinical and radiographic outcomes in the treatment of chronic AC dislocations.

Method

The Cochrane Library, EMBASE, and PubMed databases were searched for literature on chronic AC dislocations from data inception to June 30, 2021. Patient data were pooled using standard meta-analytic approaches. The Cochrane-Mantel–Haenszel method and variance-weighted means were used to analyze the outcomes. The Review Manager version 5.3 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) was used to calculate the heterogenicity, mean difference, and relative risk (RR) for all outcomes in the meta-analysis.

Results

The current analysis included four trials on this topic, and all AC joint dislocations were classified as Rockwood types III to VI. The pooled data showed that the CCR group had significantly better post-operative American Shoulder and Elbow Surgeons Shoulder (ASES) scores, Oxford Shoulder Scores (OSSs), and Nottingham Clavicle Scores (NCSs) than the WD group, with a significant difference (p < 0.001, p = 0.020, and p < 0.001, respectively). In terms of the post-operative Constant-Murley Scores (CMSs), there were no significant differences between the CCR group and the WD group (p = 0.100). The CCR group had significantly better post-operative abduction and flexion of the index shoulder than the WD group (p < 0.001 and p < 0.001, respectively). In terms of radiological outcomes, the post-operative coracoclavicular distance (CCD) with a 10 kg load was smaller in the CCR group compared to that in the WD group (p < 0.001). The overall surgical wound infection rate was 11.6% in the WD group and 12.9% in the CCR, respectively (p = 0.82).

Conclusion

The CCR group had better clinical outcome scores in the ASES, OOS, NCS, abduction, flexion, and external rotation than the WD group. In terms of radiological outcomes, the CCR group showed less displacement in weight-loaded post-CCD than the WD group, which indicated that the CCR provided more stability and resistance to deformation forces.

Grade III Acromioclavicular Separations Treated With Suspensory Fixation Techniques: A Systematic Review of Level I Through IV Studies

Purpose

To perform a systematic review comparing clinical outcomes, radiographic outcomes, and complication rates after acute (surgery ≤6 weeks from injury) versus chronic (surgery >6 weeks from injury) acromioclavicular joint reconstructions for grade III injuries using modern suspensory fixation techniques.

Methods

We performed a systematic review of the literature examining acute versus chronic surgical treatment of Rockwood grade III acromioclavicular joint separations using the Cochrane registry, MEDLINE database, and Embase database over the past 10 years according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria included techniques using suspensory fixation, a minimum study size of 3 patients, a minimum follow-up period of 6 months, human studies, and English-language studies. The methodology of each study was evaluated using the Methodological Index for Non-randomized Studies (MINORS) tool for nonrandomized studies and the revised Cochrane risk-of-bias (RoB 2) tool for randomized controlled trials.

Results

The systematic review search yielded 20 studies with a total of 253 patients. There were 2 prospective randomized controlled trials, but most of the included studies were retrospective. On comparison of acute surgery (≤6 weeks) and chronic surgery (>6 weeks), individual studies reported a range of Constant scores of 84.4 to 98.2 and 80.8 to 94.1, respectively. The ranges of radiographic coracoclavicular distances reported at final follow-up also favored acute reconstructions, which showed improved reduction (9.2-15.7 mm and 11.7-18.6 mm, respectively). The reported complication rates ranged from 7% to 67% for acute reconstructions and from 0% to 30% for chronic reconstructions.

Conclusions

The ranges in the Constant score may favor acute reconstructions, but because of the heterogeneity in the surgical techniques in the literature, no definitive recommendations can be made regarding optimal timing.

Level of Evidence

Level IV, systematic review of Level I through IV studies.

Concomitant Acromioclavicular and Coracoclavicular Ligament Reconstruction with a Duo-Figure-8 Autogenic Graft Wrapping Technique for Treating Chronic Acromioclavicular Separation

Backgroud

Coracoacromial ligament transfer is the traditional procedure for treating chronic acromioclavicular separation, but it is significantly inferior to ligament reconstruction according to biomechanical and clinical studies. However, ligament reconstruction carries the risk of complications of graft loosening and peri-tunnel fractures. Currently, there is no ligament reconstruction procedure optimal for preventing such complications. The purpose of this study was to describe and retrospectively analyze the clinical and radiological outcomes of a “duo-figure-8” autogenic graft wrapping technique, which was used to concomitantly reconstruct the acromioclavicular and coracoclavicular ligaments.

Methods

Preoperative, immediate postoperative, and final follow-up oputcomes were evaluated in 10 enrolled patients. Radiographic outcomes were indicated by the bilateral difference of the coracoclavicular distance (CCD) and overlapping length of the acromioclavicular joint (OLac). Quality of reduction was classified into 4 grades according to bilateral CCD difference into overreduction (< 0 mm), anatomic reduction (0–4 mm), partial loss of reduction (4–8 mm), and recurrent dislocation (> 8 mm). Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) and Constant scores.

Results

The mean side-to-side differences for CCD were 11.9 mm (preoperative), −0.1 mm (immediate postoperative), and 3.4 mm (final follow-up); those for OLac were 9.4 mm (preoperative) and 2.7 mm (final follow-up). CCD and OLac outcomes significantly improved at final follow-up (p < 0.05). At the immediate postoperative stage, 6 and 4 patients had overreduction and anatomic reduction, respectively. At final follow-up, 7 and 3 patients had anatomic reduction and partial loss of reduction, respectively. The magnitude of improvement of ASES scores for patients with anatomic reduction and partial loss of reduction (p = 0.20) was 18.1 and 20.0, respectively. The magnitude of improvement of Constant scores in patients with anatomic reduction and partial loss of reduction (p = 0.25) was 19.9 and 22.3, respectively.

Conclusions

The technique yielded acceptable functional outcomes in patients with anatomic reduction or partial loss of reduction. The “duo-figure-8” wrapping method—a single autogenic tendon graft passing beneath the coracoid process with a tendon-knot fixation over the distal clavicle and looping around the acromion intramedullary—did not increase the risk of peri-tunnel fractures over the clavicle, coracoid process, or acromion.

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

PURPOSE

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

METHODS

Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of chronic acromioclavicular joint dislocations were included. Following data were extracted: authors and year, study design, level of evidence, number of patients, age, classification of acromioclavicular joint dislocation, time to surgery, surgical technique, follow-up, clinical and imaging outcomes, complications and failures. Descriptive statistics was used, when a data pooling was not possible. Comparable outcomes were pooled to generate summary outcomes reported as frequency-weighted values. Quality appraisal was assessed through the MINORS checklist.

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Allo- and autografts show comparable outcomes in chronic acromioclavicular joint reconstruction: a systematic review

PURPOSE

The aim of this review was to compare clinical and radiological outcome of acromio-clavicular joint reconstruction with allografts versus autografts.

METHODS

The PubMed, MEDLINE, The Cochrane Library and WEB OF SCIENCE databases were searched in accordance with the PRISMA guidelines until February 2020 using the terms: 'coracoclavicular' OR 'coraco-clavicular' OR 'acromioclavicular' OR 'acromio-clavicular joint', AND 'reconstruction'. All studies reporting on clinical and radiological outcome as well as complications after ACJ reconstruction using allo- and/or autografts were included.

RESULTS

A total of 29 articles, including 2 prospective and 27 retrospective studies, involving 622 patients, reconstructed with either allo- (n = 360) or auto-grafts (n = 262), for acromio-clavicular joint instability were identified and included in this review. The majority of studies had low sample sizes (66.7% below n = 20), were retrospective (93.3%), with short-term follow-ups (average 26.2 ± 12.6 months; range 6-186). The study with the largest sample size (n = 128) did not report clinical outcome. A comparison between allo- and auto-graft showed no significant differences regarding age, gender, and follow-up times. Clinical outcome was comparable in both groups, loss of reduction (LOR) and complication rates were higher in the allograft group. Overall a reduction of LOR was shown if additional horizontal stabilization was performed. Also a higher LOR and revision rate was documented in allografts without suture or suture-tape augmentation. The use of more clavicular drill-holes correlated with a higher frequency of fracture.

CONCLUSIONS

A systematic review of the available peer-reviewed literature addressing allograft and autograft reconstruction of unstable coracoclavicular ligaments shows that the published studies are generally of low quality with low levels of evidence. The published literature shows no significant difference in clinical outcomes between the use of autografts or allografts in ACJ reconstruction surgery. Surgical techniques utilizing additional horizontal stabilization may contribute to lower rates of LOR. In cases where allograft tissue is used for ACJ reconstruction the use of suture/tape augmentation may reduce LOR rates as well as revision rates.

LEVEL OF EVIDENCE

III.

Long-term stability of coracoclavicular suture fixation for acute acromioclavicular joint separation

PURPOSE

The optimal (SBJI) surgical treatment for acute acromioclavicular (AC) joint disruption remains controversial. What is being presented is the long-term functional outcomes of a double cross-looped coracoclavicular (CC) suture technique with the intention of restoring both anteroposterior and superior displacement of the clavicle.

METHODS

Between 2007 and 2016, 81 patients underwent surgical reconstruction for acute acromioclavicular joint (AC) disruption in two orthopaedic centers. Two patients died for reasons unrelated to the treatment, and seven missed the final follow-up appointment, leaving 72 patients (67 males; 5 females; age 37 ± 12.4; range 15-64 years) for clinical and radiological assessments. All cases were classified according to the Rockwood classification as type III (n = 34), IV (n = 14) or V (n = 24). The dislocation was repaired with double cross-looped CC fixation using four Ethibond sutures passing underneath the coracoid and through a 4.5 mm drill hole in the clavicle in opposing directions to control both anteroposterior and vertical displacement. Radiological investigation preoperatively and at the last follow-up included anteroposterior and/or Zanca views, axillary or Alexander views, and comparative stress radiography of both AC joints. Patients were evaluated clinically with the Constant-Murley score (CMS) and Acromio Clavicular Joint Instability Score (ACJIS). Loss of reduction, subluxation, CC ligament ossification, post-traumatic arthritis, and peri-implant fractures were also recorded.

RESULTS

Seventy-two patients were available for the last clinical and radiological evaluations. At a median follow-up period of 6.3 ± 2.1 years (range 3-12 years), the CMS and ACJIS were 92.1 ± 7.2 (range 60-100 points) and 90.4 ± 8.6 (range 45-100 points), respectively. Complications included 9 (12.5%) patients with slight loss of reduction, 2 (1.7%) with dislocation recurrence, 1 (1.3%) with superficial infection, 1 (1.3%) with a fracture of the lateral end of the clavicle, and 2 (1.7%) with persistent tenderness in the AC joint. The incidence of periarticular ossification was 22.4% and did not affect the final outcome.

CONCLUSIONS

This technique represents an effective and low-cost treatment for acute AC joint separations.

LEVEL OF EVIDENCE

IV.

Rockwood Grade-III Acromioclavicular Joint Separation: A Cost-Effectiveness Analysis of Treatment Options

Background:

The treatment of Rockwood Grade-III acromioclavicular (AC) joint separation has been widely disputed since the introduction of the classification system. The present literature does not reach consensus on whether operative or nonoperative management is more advantageous, nor does it effectively distinguish between operative measures. We hypothesized that nonoperative treatment of Rockwood Grade-III AC joint separation would be more cost-effective when compared with surgical options.

Methods:

We created a decision-tree model outlining the treatment of Rockwood Grade-III separations using nonoperative management or hook-plate, suture-button, or allograft fixation. After nonoperative intervention, the possible outcomes predicted by the model were uneventful healing, delayed operative management, a second round of sling use and physical therapy, or no reduction and no action; and after operative intervention, the possible outcomes were uneventful healing, loss of reduction and revision, and depending on the implant, loss of reduction and no action, or removal of the implant. A systematic review was conducted, and probabilities of each model state were averaged. A cost-effectiveness analysis was conducted both through rollback analysis yielding net monetary benefit and through incremental cost-effectiveness ratios (ICERs). Thresholds of $50,000/quality-adjusted life-year (QALY) and $100,000/QALY were used for ICER analysis. Furthermore, a sensitivity analysis was utilized to determine whether differential probabilities could impact the model.

Results:

Forty-five papers were selected from a potential 768 papers identified through our literature review. Nonoperative treatment was used as our reference case and showed dominance over all 3 of the operative measures at both the $50,000 and $100,000 ICER thresholds. Nonoperative treatment also showed the greatest net monetary benefit. Nonoperative management yielded the lowest total cost ($6,060) and greatest utility (0.95 QALY). Sensitivity analysis showed that allograft fixation became the favored technique at a willingness-to-pay threshold of $50,000 if the rate of failure of nonoperative treatment rose to 14.6%. Similarly, at the $100,000 threshold, allograft became dominant if the probability of failure of nonoperative treatment rose to 22.8%.

Conclusions:

The cost-effectiveness of nonoperative treatment is fueled by its notably lower costs and overall high rates of success in Grade-III separations. It is important to note that, in our analysis, the societal cost (measured in lost productivity) of nonoperative treatment neared that of surgical treatment, but the cost from the health-care system perspective was minimal. Physicians should bear in mind the sensitivity of these conclusions and should consider cost-effectiveness analyses in their decision-making guidelines.

Level of Evidence:

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

The long-term efficacy of the GraftRope technique

BACKGROUND

Acromioclavicular joint separations continue to be a challenge for surgeons, and modern arthroscopically assisted techniques are becoming increasingly widespread. The aim of this study is to evaluate if the use of a biological support in association with a nonresorbable subcoracoid fixation can improve long-term stability in acromioclavicular joint dislocation surgically treated. We assessed clinical and radiographic results, patients' return to daily activities and the risk of complications.

MATERIALS AND METHODS

Fourteen patients underwent subcoracoid fixation with the GraftRope system for chronic Rockwood type IV acromioclavicular joint dislocation. A total of 12 patients were evaluated clinically and radiologically with a minimum of 7 years of follow-up.

RESULTS

Good reduction was obtained in all patients. All patients returned to work and sports at the pretrauma level with high mean scores on clinical evaluation. Regarding complications, 3 patients developed acromioclavicular arthritis. Ossifications were a common finding on x-rays, but they did not worsen the clinical outcome.

CONCLUSIONS

The GraftRope surgical technique allows us to obtain an anatomical reduction of the acromio-clavicular joint, along with the restoration of the mechanical properties of the joint, owing to the use of a biological material with rigidity and load resistance features. Clinical results over the long term are encouraging. However, a 6-mm bone tunnel is too large since the average thickness of the coracoid process is only approximately 12 mm. This technique has some advantages over others: it avoids detachment of the deltoid, avoids the use of bulky metal implants with an important dissection of soft tissue, while it has all the advantages of an arthroscopic procedure.

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.

Chronic acromioclavicular dislocations: multidirectional stabilization without grafting

Objective

Clinical and radiological evaluation of the surgical treatment of chronic acromioclavicular (AC) dislocations with triple button device and AC joint augmentation.

Materials and Methods

This retrospective study included 21 patients with chronic AC dislocations. All patients underwent bilateral-weighted Zanca and Alexander views as well as the Constant score (CS) and Acromioclavicular Joint Instability Scoring System (ACJI).

Results

A total of 21 patients (19 men and 2 women) with the mean age of 30.7 ± 11.7 years (range, 19-62 years) were able to participate in clinical and radiographic follow-up. After a mean follow-up of 49.7 ± 17.1 months (range, 13-60 months), the results of the CS were 95.2 ± 5.5 (range, 85-100) and ACJI test 89.7 ± 7.9 (range, 75-100), showing no significant differences with the uninjured shoulder (CS, 96.2 ± 3.9; range, 85-100; ACJI, 95.7 ± 4.1; range, 85-100). At the final review, we observed that the preoperative coracoclavicular distance (Zanca view) improved from 12.8 ± 1.5 mm to 8.5 ± 1.3 mm and the AC distance (Alexander view) from 7.8 ± 2.3 mm to 0.99 ± 0.91 mm. Compared with healthy shoulder, these differences were not significant. Osteoarthritis or radiological calcifications were not associated with worse clinical outcomes.

Conclusion

The triple button device is an acceptable alternative surgical method for chronic AC joint dislocations. The surgical technique is simple; it does not need a graft, nor does it present major complications, and material extraction is unnecessary.

The Infinity-Lock System for Chronic Grade III AC Joint Dislocation: A Novel Technique, Rehabilitation Protocol and Short Term Results

Background: the choice of treatment of chronic grade III acromioclavicular (AC) joint dislocation is controversial. Several surgical techniques have been described in the literature, responding differently to nonoperative treatment. The aim of this study is to describe a modified technique of stabilizing an AC joint dislocation with the new Infinity-Lock Button System, in order to demonstrate that it is effective in optimizing outcomes and decreasing complications. Methods: this is a retrospective study of 15 patients who underwent surgical stabilization of the AC joint dislocation between 2018 and 2019, through modified surgical technique using the Infinity-Lock Button System. Active range of motion (ROM), Specific Acromio Clavicular Score (SACS) and Constant Score (CS) were evaluated preoperatively and postoperatively at last 18 months follow up. Patients rated their outcomes as very good, good, satisfactory, or unsatisfactory. Results: a total of twelve patients rated their outcome as very good and three as good; no patients were dissatisfied with surgery. The mean Constant Score increased from 38 points preoperatively to 95 postoperatively, the average SACS score decreased from 52 points preoperatively to 10 postoperatively, both significantly. No complications were detected. Conclusion: the described technique is effective for treatment of chronic grade III AC joint dislocation, resulting in elevated satisfaction ratings and predictable outcomes. Nevertheless, further longer term follow-up studies are required.

Synthetic coracoclavicular ligament vs. coracoclavicular suspensory construct for treatment of acromioclavicular dislocation: a biomechanical study

BACKGROUND

A synthetic ligament (LockDown, Worcestershire, England) has become available to treat complete acromioclavicular dislocation with promising clinical results and potential benefit to avoid postoperative loss of reduction. We investigated the biomechanics of this synthetic ligament in a simulated immediate postoperative rehabilitation setting, hypothesizing that the synthetic ligament would demonstrate less superior coracoclavicular displacement to cyclic loading and higher ultimate load-to-failure values than a coracoclavicular suspensory construct.

METHODS

Seven matched-pair cadaveric shoulders (mean age at time of death, 79 years) were loaded cyclically and to failure. One specimen in each pair was randomly assigned to the synthetic ligament or coracoclavicular suspensory construct. Superiorly directed 70-N cyclic loading for 3000 cycles at 1.0 Hz was applied through the clavicle in a fixed scapula simulating physiologic states during immediate postoperative rehabilitation, followed by a load-to-failure test at 120 mm/min.

RESULTS

After 3000 cycles, the superior displacement of the clavicle in the synthetic ligament (9.2 ± 1.1 mm) was 225% greater than in the coracoclavicular suspensory construct (2.8 ± 0.4 mm, 95% confidence interval [CI] 3.4, 8.3; P < .001). Average stiffness of the synthetic ligament (32.8 N/mm) was 60% lower than that of the coracoclavicular suspensory construct (81.9 N/mm, 95% CI 43.3, 54.9; P < .001). Ultimate load-to-failure of the synthetic ligament was 23% (95% CI 37.9, 301.5; P = .016) lower than the coracoclavicular suspensory construct (580.5 ± 85.1 N and 750.2 ± 135.5 N, respectively).

CONCLUSION

In a simulated immediate postoperative cadaveric model, the synthetic ligament demonstrated poorer biomechanics than the coracoclavicular suspensory construct. These findings suggest that a coracoclavicular suspensory construct may be preferable to a synthetic ligament if early rehabilitation is intended.

Systematic review of the treatment of acromioclavicular joint disruption comparing number of tunnels and graft type

BACKGROUND

The management of high-grade acromioclavicular separations remains unclear. The surgical interventions have shifted to more anatomic, less invasive techniques. The purpose of this study was to systematically review the outcomes and complications of anatomic coracoclavicular ligament reconstruction using a tendon graft.

METHODS

Twenty-one studies (n = 460 patients) met the criteria for inclusion. A double clavicle tunnel tendon graft construct was used in 348 patients (75.7%), whereas a single clavicle tunnel technique was used in 112 patients (24.3%). No significant difference in loss of reduction was found between the 2 techniques. Of 460 patients, 96 (20.9%) demonstrated some form of radiographic displacement at the final follow-up. The overall complication rate was 21.3% (98 of 460), and a higher complication rate was found in the double clavicle tunnel technique (P < .001). The overall reoperation rate was 7.6% (37 of 460). The most common reason for reoperation was clavicle fracture (8 of 37). There was a statistically significant increase in reoperation when allograft was used (P = .003).

CONCLUSION

The results of this study suggest that despite newer techniques, approximately 20% of patients develop loss of reduction and/or experience a surgical complication. Attempts to minimize trauma to the clavicle and use autograft tendon may reduce the risk of reoperation.

Modified Weaver-Dunn Procedure for Type 3 Acromioclavicular Joint Dislocation: Functional and Radiological Outcomes

Background

Controversy surrounds the indication for treatment of type 3 acromioclavicular joint dislocation, and the optimal reconstructive technique has not yet been defined. Since the first description of the Weaver-Dunn procedure, several studies have described the clinical and radiological results that can be expected postoperatively; however, few studies have evaluated the outcomes of this technique for chronic type 3 acromioclavicular joint dislocation.

Purpose/Hypothesis

The purpose of this study was to evaluate the functional and radiographic mid- to long-term outcomes of a modified Weaver-Dunn procedure for chronic Rockwood type 3 acromioclavicular joint dislocation. We hypothesized that (1) functional outcomes comparable with sex- and age-matched healthy individuals could be achieved with the modified Weaver-Dunn procedure and (2) joint stability could be restored after surgery.

Study Design

Case series; Level of evidence, 4.

Methods

Out of 30 patients who sustained a chronic type 3 acromioclavicular joint dislocation, 27 had a minimum 12-month follow-up and were included in the study. All patients underwent a modified Weaver-Dunn procedure. The Constant-Murley score was used to assess patient postoperative function. Subjective evaluation of patient satisfaction with surgery was also recorded. Radiological assessment was performed postoperatively to evaluate superoinferior and anteroposterior joint stability.

Results

After a mean follow-up period of 51.6 months, the mean Constant-Murley score was 90.1, which was 97.2% that of a group of sex- and age-matched healthy individuals. In the multivariate analysis, higher Constant-Murley score was associated with male sex (β = 0.385; P = .043) and higher subjective satisfaction scale (β = 0.528; P = .003). All patients returned to their previous work and sport activity levels having high satisfaction with surgery. Successful vertical acromioclavicular joint reduction was obtained in all but 1 patient; however, horizontal joint stability was not completely restored with the modified Weaver-Dunn procedure. No intraoperative complications occurred, and the postoperative complication rate was 7.4%.

Conclusion

In patients with chronic type 3 acromioclavicular joint dislocation, the modified Weaver-Dunn procedure is an effective technique to restore vertical but not horizontal joint stability 4 years after surgery. High levels of satisfaction with surgery and functional outcomes comparable with sex- and age-matched healthy individuals can be achieved.

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.

Horizontal Instability of the Acromioclavicular Joint: A Systematic Review

BACKGROUND

Injuries to the acromioclavicular (AC) joint are common and should be suspected in patients who have shoulder pain in the region of the acromion and clavicle. Injuries to the AC ligament can cause horizontal instability and are often neglected or underdiagnosed, which can lead to poor patient outcomes.

PURPOSE

To perform a systematic review of the literature on the diagnosis and treatment of horizontal instability of the AC joint.

STUDY DESIGN

Systematic review.

METHODS

The authors performed a systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies that investigated diagnosis, treatment, and failure of operative management of acute and chronic AC separations. Studies that did not specifically evaluate AC joint injuries, were not written in English, or were specific only to vertical instability of the AC joint were excluded.

RESULTS

Overall, 23 articles met the inclusion criteria and were therefore included in this systematic review. Diagnosing horizontal AC instability is difficult using plain radiographs; dynamic views were shown in some cases to better detect horizontal instability than with static views. More than 60 procedures for treating AC joint injuries have been published, but many focus on vertical rather than horizontal instability. Modifications to current surgical procedures to incorporate reconstruction of the horizontal component showed improved patient outcomes. Such modifications included additional AC joint suture cord cerclage, combined AC and coracoclavicular ligament reconstruction, and the Twin Tail TightRope triple button technique. Failure after surgical stabilization of AC joint separation has been reported to occur in 15% to 80% of cases.

CONCLUSION

No consensus is available regarding the best practices for diagnosis, evaluation, and treatment of acute or chronic horizontal instability of the AC joint. Moreover, horizontal instability injuries are often neglected or poorly understood, making diagnosis difficult, which may lead to high complication rates and failure after surgical stabilization.

Anatomic and non-anatomic reconstruction improves post-operative outcomes in chronic acromio-clavicular instability: a systematic review

PURPOSE

To systematize the surgical outcomes of anatomic and non-anatomic reconstruction in patients with chronic acromio-clavicular joint (ACJ) instability and determine which technique is superior.

METHODS

This review was conducted according to the PRISMA guidelines. PubMed and Cochrane Library databases were searched up to April 30th, 2018 for original articles that assessed the outcomes of one or more surgical techniques of anatomic and non-anatomic reconstruction in patients with chronic ACJ instability. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Pre-to-post meta-analysis was performed for both anatomic and non-anatomic reconstructions.

RESULTS

Twenty-eight studies were included comprising 799 patients (mean age of 36.6 years old and 84% males) with a mean follow-up of 34.6 months (range 13 to 74). Surgical techniques included anatomic (tendinous or synthetic grafts/constructs) and non-anatomic reconstruction (Weaver-Dunn or Modified Weaver-Dunn, conjoined tendon transfer, or temporary hook plate). There were significant pre-to-post improvements on the constant score with an average improvement ranging from 11.1 to 50.7 (p < 0.01). Average failure rate was 7.6% (7.5% for anatomic and 8.5% for non-anatomic reconstruction). Non-comparative studies had a mean MINORS score of 9 points (out of 16) and comparative studies 17 (out of 24) with excellent interrater agreement (k = 0.910).

CONCLUSION

Both anatomic and non-anatomic ACJ reconstructions provide significant post-operative improvements, but definitive conclusions on optimal technique remain elusive. Notwithstanding, comparative studies support the use of anatomic ACJ reconstruction which should be preferably used. However, until superiority is demonstrated by robust studies, surgeons should supplement their decision-making with experience and patient preference.

LEVEL OF EVIDENCE

IV.

Surgical management of chronic high-grade acromioclavicular joint dislocations: a systematic review

BACKGROUND

To date, no gold-standard technique exists for the treatment of chronic acromioclavicular joint (ACJ) instability. We systematically reviewed the clinical results of 3 main categories of ACJ reconstruction for high-grade chronic instability.

METHODS

A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The inclusion criteria were clinical studies involving patients with ACJ instability (Rockwood grades III-VI) for at least 6 weeks, managed with ACJ stabilization, with a minimum 1-year follow-up. Depending on the surgical technique, patients were divided into 1 of 3 groups: nonbiological fixation between the coracoid and clavicle, for example, suture loops and synthetic ligaments (group 1); biological reconstruction of the coracoclavicular ligaments, for example, allograft or autograft ligament reconstruction (group 2); and ligament and/or tendon transfer, for example, the Weaver-Dunn procedure (group 3). Patient demographic characteristics, functional scores, radiographic outcomes, and complications were compared.

RESULTS

Two independent investigators reviewed 960 articles. A total of 27 studies met the inclusion criteria, comprising 590 patients divided into 1 of 3 groups. The complication rates were similar among the 3 groups: 15% for nonbiological fixation, 15% for biological reconstruction, and 17% for ligament and/or tendon transfer, with failure rates of 8%, 7%, and 5%, respectively. In terms of functional results, the mean Constant score was 87.2 points for nonbiological fixation (n = 89), 92.4 points for biological reconstruction (n = 86), and 87.4 points for ligament and/or tendon transfer (n = 49).

CONCLUSION

On comparison of the results of 3 different ACJ reconstruction methods, all techniques showed similar complication rates. Among the level II studies, ACJ reconstruction with a tendon graft showed superior results.

Detection of the palmaris longus tendon: physical examination versus sonography

This study investigated the sensitivity, specificity, and accuracy of physical examination compared with high resolution sonography for the detection of the palmaris longus tendon in 136 wrists. The incidence of tendon absence was 10% by sonography and 14% by physical examination. The sensitivity of the physical examination was 94% and the specificity 86% compared with sonography as the reference standard. Accurate identification of the palmaris longus tendon through physical examination was not influenced by body mass index or wrist circumference. Upon review of the sonography images, none of the palmaris longus tendons missed on physical examination were considered to be adequate for grafting based on expert opinion. While physical exam was 93% accurate for detection of the palmaris longus tendon compared with ultrasound, our study suggests that it is sufficient for detection of those tendons that can be used as donors clinically.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSION

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

Biomechanical Comparison of Anatomic and Extra-Anatomic Reconstruction Techniques Using Local Grafts for Chronic Instability of the Acromioclavicular Joint

BACKGROUND

Anatomic reconstruction techniques are increasingly used to address cases of acromioclavicular (AC) joint chronic instability. These usually involve an additional surgical site for autograft harvesting or an allograft.

PURPOSE

To describe a triple-bundle (TB) anatomic reconstruction using on-site autografts, the semiconjoint tendon (SCT) and the coracoacromial ligament (CAL), and compare its primary stability to the native AC joint ligamentous complex and to a modified Weaver-Dunn (WD) reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Intact AC joints of 12 paired cadaveric shoulders were tested for anterior, posterior, and superior translations under cyclic loading with a servo-hydraulic testing system. One shoulder from each pair was randomly assigned to the TB group, where 2 SCT strips were used to reconstruct the coracoclavicular ligaments while the distal end of the CAL was transferred to the distal extremity of the clavicle to reconstruct the AC ligaments; the other shoulder received a modified WD reconstruction. After reconstruction, the same translational testing was performed, with an additional load-to-failure test in the superior direction.

RESULTS

In both the TB and the WD groups, no significant differences were found before and after reconstruction in terms of joint displacements after cyclic loading, in all 3 directions. Compared with the WD reconstruction, the TB repair resulted in significantly lower displacements in both the anterior (ie, 2.59 ± 1.08 mm, P = .011) and posterior (ie, 10.17 ± 6.24 mm, P = .014) directions, but not in the superior direction. No significant differences were observed between the 2 reconstructions during the load-to-failure testing, except for the displacement to failure, which was significantly smaller (ie, 5.34 ± 2.97 mm) in the WD group ( P = .037).

CONCLUSION

Anterior, posterior, and superior displacements after an anatomic reconstruction of the AC joint complex using the SCT and CAL as graft material were similar to those of native AC joints and significantly smaller in the axial plane than those of AC joints after a WD repair.

CLINICAL RELEVANCE

An anatomic reconstruction is achievable using the CAL and the SCT as on-site graft materials, providing satisfactory initial stability and thereby allowing earlier mobilization.

Acromioclavicular and Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Instability: A Systematic Review of Clinical and Radiographic Outcomes

PURPOSE

To perform a systematic review of the available literature on clinical and radiographic outcomes after surgical treatment for acromioclavicular (AC) joint instability.

METHODS

A systematic review was performed according to PRISMA guidelines. Inclusion criteria were AC joint and coracoclavicular (CC) ligament reconstruction outcomes, English language, human studies, more than 10 patients in the study and a 2-year minimum follow-up. Exclusion criteria were animal studies, cadaveric studies, clinical studies without reported follow-up period or patient-reported outcomes, clinical studies of nonoperative treatment, AC reconstructions with concurrent lateral clavicle fracture, editorial articles, abstracts, presentations, reviews, case reports, and surveys.

RESULTS

The systematic review identified 34 studies (939 patients) after inclusion and exclusion criteria application. Postoperative American Shoulder and Elbow Surgeons (ASES) scores ranged from 93.8 to 96, 81.8 to 97.8, and 88.1 for free tendon graft, suspensory devices, and modified Weaver-Dunn techniques, respectively. Postoperative Constant scores were 76.4 to 96.0, 82.6 to 97.8, 85.9 to 97.0, 81 to 96 and 83.0 to 94.6 for free tendon graft, suspensory devices, synthetic ligament devices, modified Weaver-Dunn, and hook plate/K-wires techniques, respectively. All treatment modalities improved patient outcomes; however, hook plates and K-wires had the highest rate of complications (26.3%). Unplanned reoperation rates were 1.2%, 2.8%, 0.9%, 5.4%, and 2.6% in free tendon graft, suspensory devices, synthetic ligament devices, modified Weaver-Dunn, and hook plate/K-wires techniques, respectively.

CONCLUSIONS

Comparable subjective outcomes after surgical treatment of AC joint instability was reported for all modalities, with relatively low unplanned reoperation rates. Treatment with hook plate/K-wires was associated with the highest complication rates, and modified Weaver-Dunn had the highest unplanned reoperation rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.