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

Progressive Loss of Acromioclavicular Joint Reduction Correlated with Progressive Clavicular Tunnel Widening after Coracoclavicular Stabilization in Acute High-Grade Acromioclavicular Joint Injury

Objectives: This study aimed to compare 24-month radiographic follow-ups of clavicular tunnel widenings (CTWs) and coracoclavicular distances (CCDs) and examine correlations between these measurements in patients following combined coracoclavicular stabilization and acromioclavicular capsule repair in treatment of acute high-grade acromioclavicular joint injury. Methods: This retrospective study reviewed the records of patients with acute Rockwood type V acromioclavicular joint injury who underwent surgery within 3 weeks after their injury. All patients had follow-ups at 3 and 6 months and 1 and 2 years. The CTWs were measured on anteroposterior radiographs between the medial and lateral borders at the superior, middle and inferior levels of the tunnels. On anteroposterior radiographs of both clavicles, the CCDs were measured at the shortest distance between the upper border of the coracoid process and the inferior border of the clavicle and reported as the CCD ratio, which was defined as the ratio of the affected and unaffected clavicles. At the final follow-ups, clinical outcomes were assessed using American Shoulder and Elbow Surgeons (ASES) scores. Results: This study included seventeen men and six women with a mean age of 47.26 ± 10.68 years. At the final follow-ups, the mean ASES score of all patients was 95.28 ± 3.62. We found a significant correlation between the increase in the CTWs and the increase in the CCD ratios (Spearman's rho correlation coefficient range 0.578-0.647, all p-values < 0.001). Conclusions: We found long-term postoperative widening of the clavicular tunnels, which correlated positively with a gradual postoperative decline in the acromioclavicular joint alignment reductions.

Eponymous terms in acromioclavicular joint surgery

Eponymization serves as a means of paying tribute to individuals who have made significant contributions to our culture. Each eponym is often linked with a story for everyone to discover. To aid in the retention of these stories, this review offers readers an overview of the individuals behind the eponymous terms, as well as their original descriptions, within the context of acromioclavicular joint pathology and orthopaedic surgery.

Acromioclavicular joint separation: Controversies and treatment algorithm

In this article, we present an uptodate outline of acromioclavicular (AC) joint separation. A clear understanding of acromioclavicular joint injury in terms of the mechanism of injury, clinical picture, diagnostic imaging, and most updated surgical techniques used for the treatment can provide the best care for those patients. This article describes updated treatment strategies for AC separation, including type III AC separation which is known most controversial. Finally, we present a proposed treatment algorithm that can aid in the treatment of AC separation from the most updated evidence.

Complications after operative treatment of high-grade acromioclavicular injuries

BACKGROUND

Treatment of Rockwood type III-V acromioclavicular (AC) joint injuries remains controversial. Numerous reconstruction techniques have been proposed. The purpose of this study was to describe the complication profile in a large cohort of patients who underwent surgical management of AC joint separations using a variety of reconstruction strategies.

METHODS

All patients who underwent surgery for AC joint injuries from 2013 to 2019 at a single institution were identified. Chart review was performed to capture patient demographics, radiographic measurements, operative techniques, postoperative complications, and revision surgery. Structural failure was defined as a radiographic loss of reduction of greater than 50% when comparing immediate and final postoperative imaging. Logistic regression analysis was performed to identify risk factors for complications and revision surgery.

RESULTS

Of the 279 patients included in the study, 66 (24%) had type III separations, 20 (7%) type IV, and 193 (69%) type V. Fifty-three percent underwent surgery acutely (<6 weeks of injury), and 40% were chronic (>3 months). A total of 252 of the 279 surgeries (90%) were performed open and 27 (10%) were arthroscopically assisted. Allograft was used in 164 of 279 (59%) cases. Specific operative techniques (with or without allograft) included hook plating (1%), modified Weaver Dunn (16%), cortical button fixation (18%), and suture fixation (65%). At mean 28-week follow-up, 108 complications were identified in 97 patients (35%). Complications were identified at mean 20 ± 21 weeks. Sixty-nine structural failures (25%) were identified. Persistent AC joint pain requiring injection, clavicle fracture, adhesive capsulitis, and hardware complications were the other most common complications. Twenty-one patients (8%) underwent unplanned revision surgery at mean 38 ± 28 weeks after the index procedure, with the most common indication for structural failure, hardware complications, or fracture of the clavicle or coracoid. Patients who had surgery after 6 weeks from injury had a significantly greater risk of having a complication (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.34-7.77, P = .009) and a significantly greater risk of having structural failure (OR 2.65, 95% CI 1.38-5.28, P = .004). Patients who had an arthroscopic technique had a greater risk of structural failure (P = .002). Complications, structural failure, and revision surgery were not significantly correlated with use of allograft or specific operative techniques.

CONCLUSION

Surgical management of AC joint injuries is associated with a relatively high complication profile. Loss of reduction in the postoperative period is common. However, the revision surgery rate is low. These findings are important for patient preoperative counseling.

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.

Acromioclavicular Joint Injuries in Sport

ABSTRACT

Sport-related shoulder injuries, including disruptions to the acromioclavicular joint (ACJ), are common. An ACJ injury is classified by the degree and direction of the clavicle displacement. Although the diagnosis can be made clinically, standard radiographic views are important to determine the severity of the ACJ disruption and assess for concurrent injuries. The majority of ACJ injuries can be managed nonoperatively; however, surgical treatment is indicated in some cases. Long-term outcomes are generally favorable for most ACJ injuries, and athletes generally return to sport without functional limitations. This article provides an in-depth discussion regarding all aspects of ACJ injuries, including clinically relevant anatomy, biomechanics, evaluation, treatment, and complications.

No correlation exists between coracoid tunnel widening and loss of reduction after arthroscopic acromioclavicular fixation using tightrope system

PURPOSE

To detect the widening of the tunnel of the coracoid process after arthroscopic fixation of acute acromioclavicular joint (ACJ) dislocation using the TightRope system and its correlation with loss of reduction and functional scores.

METHODS

From 2016 to 2018, a prospective study was performed on twenty-three patients with acute grade III-V ACJ dislocation. Arthroscopic TightRope repair of the ACJ was performed. Coracoid tunnel widening was measured by CT, and the coracoclavicular distance was measured on the radiographs immediately postoperatively and at 12 months. The Constant Shoulder Score, Oxford Shoulder Score, Nottingham Clavicle Score and Visual analog scale were used as outcome measures at 12 months.

RESULTS

The coracoid tunnel diameter to horizontal coracoid diameter ratio increased from 22.8 ± 3.7% immediately postoperatively to 38.5 ± 5.5% at 12 months (p < 0.001). The coracoclavicular (CC) distance showed an increase from a mean of 10.8 ± 1.7 mm to a mean of 11.8 ± 2.5 at 12 months (p < 0.001). There was no correlation between the increase in the coracoclavicular distance and the patients' functional clinical scores or coracoid tunnel widening.

CONCLUSION

Coracoid tunnel widening and radiological loss of reduction occur after arthroscopic fixation of acute ACJ dislocation with the TightRope system. However, they do not correlate with each other or with the functional scores of the patient.

LEVEL OF EVIDENCE

Level IV.

The Reliability of Acromioclavicular Joint Dislocation Classification Systems: A Comparison Between the Rockwood and Kraus Classifications

Background

The Rockwood system for the classification of acute acromioclavicular (AC) joint dislocations has been associated with a lack of reliability. A novel system has been proposed (Kraus classification) that is based on dynamic posterior translation of these injuries.

Purpose

To assess the interobserver and intraobserver reliability of the Rockwood and Kraus classification systems and also to examine the impact of surgeon experience on the assessments.

Study Design

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

Methods

Included were 45 patients with acute AC joint injuries who underwent a radiographic examination using standard bilateral AP and modified Alexander views. For interobserver reliability, 6 shoulder surgeons (expert group) and 6 orthopaedic residents (novice group) reviewed the radiographs to classify injuries according to the Rockwood and Kraus classifications; for each categorization, the participants chose between nonoperative management and surgical treatment. The evaluation was repeated 6 weeks later to determine intraobserver reliability. Kappa (κ) coefficients and their 95% CIs were used to compare interobserver and intraobserver reliability for each classification system according to assessor experience. Statistical differences were considered significant when the upper and lower boundaries of the 95% CI did not overlap.

Results

The overall interobserver agreement for diagnosis (both novice and expert groups) was moderate (κ = 0.52 [95% CI, 0.51-0.54]) for the Rockwood classification and substantial (κ = 0.62 [95% CI, 0.53-0.65]) for the Kraus classification; however, no significant differences were observed between the κ values. The overall interobserver agreement for treatment selection was substantial when using both the Rockwood (κ = 0.78 [95% CI, 0.72-0.81]) and Kraus (κ = 0.77 [95% CI, 0.66-0.87]) classifications. The overall intraobserver agreement for diagnosis was substantial using both the Rockwood (κ = 0.65 [95% CI, 0.61-0.67]) and Kraus (κ = 0.73 [95% CI, 0.69-0.75]) classifications. There were no significant differences between the novice and expert groups on any of the evaluations.

Conclusion

The Kraus system was slightly more reliable than the Rockwood system for classifying AC joint injuries both between assessor groups and overall. The level of surgeon experience had no impact on the evaluations.

Acromioclavicular joint suture button repair leads to coracoclavicular tunnel widening

PURPOSE

Biomechanical evaluation of three different suture button devices used in acromioclavicular joint repair and analysis of their effect on post-testing tunnel widening.

METHODS

Eighteen human shoulder girdles were assigned into three groups with a similar mean bone mineral density. Three different single-tunnel acromioclavicular repair devices were tested: (1) AC TightRope^® with FiberWire; (2) AC Dog Bone^™ Button with FiberTape; (3) Low Profile AC Repair System. Biomechanical testing was performed simulating the complex movement of the distal clavicle as follows. A vertical load of 80 N was applied continuously. The rotation of the clavicle about its long axis was set at 10° anterior and 30° posterior for 2500 cycles at 0.25 Hz. The horizontal translation of the clavicle was set at 6 mm medial and 6 mm lateral for 10,000 cycles at 1 Hz. The coracoclavicular distance was measured before and after testing. After testing, each sample underwent micro-CT analysis. Following 3D reconstruction, the area of the bone tunnels was measured at five defined cross sections.

RESULTS

In TightRope^® and Dog Bone^™ groups, all samples completed testing, whereas in the Low Profile group, three out of six samples showed system failure. The mean absolute difference of coracoclavicular distance after testing was significantly greater in the Low Profile group compared to TightRope^® and Dog Bone^™ groups (4.3 ± 1.3 mm vs 1.9 ± 0.7 mm vs 1.9 ± 0.8 mm; p = 0.001). Micro-CT analysis of the specimens demonstrated significant tunnel widening in the inferior clavicular and superior coracoid regions in all three groups (p < 0.05).

CONCLUSION

Significant tunnel widening can be observed for all devices and is primarily found in the inferior parts of the clavicle and superior parts of the coracoid. The Low Profile AC Repair System showed inferior biomechanical properties compared to the AC TightRope^® and AC Dog Bone^™ devices. Therefore, clinicians should carefully select the type of acromioclavicular repair device used and need to consider tunnel widening as a complication.

Treatment of Acromioclavicular Joint Instability With a Tunnel-Free Reconstruction Technique

Acromioclavicular joint injuries are a common shoulder injury encountered by orthopaedic surgeons. Many different surgical techniques have been described for the operative treatment of these injuries with no single, clear gold standard technique on which surgeons agree. Among the most common complications after surgical management of acromioclavicular injuries are loss of reduction, infection, fracture of clavicle or coracoid, and need for reoperation. We propose an arthroscopic-assisted, tunnel-free surgical technique using a tibialis anterior allograft combined with a FiberTape Cerclage (Arthrex, Naples, FL) to manage both acute and chronic acromioclavicular joint injuries. No bony tunnels are drilled and no hardware is implanted, which should obviate the risk for subsequent bony failure through a fracture, nor require subsequent hardware removal. In addition, the combination of suspensory and allograft fixation should impart sufficient stability to maintain an adequate reduction even in the face of failure of one of the fixation methods.

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.

Coracoid or Clavicle Fractures Associated With Coracoclavicular Ligament Reconstruction

BACKGROUND

Coracoclavicular (CC) ligament reconstruction is a commonly performed procedure for high-grade acromioclavicular (AC) joint separations. Although distal clavicle and coracoid process fractures represent potential complications, they have been described in only case reports and small case series.

PURPOSE

To identify the incidence and characteristics of clavicle and coracoid fractures after CC ligament reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The US Military Health System Data Repository was queried for patients with a Current Procedural Terminology code for CC ligament repair or reconstruction between October 2013 and March 2020. The electronic health records, including patient characteristics, radiographs, operative reports, and clinical notes, were evaluated for intraoperative or postoperative clavicle or coracoid fractures. Initial operative technique, fracture management, and subsequent clinical outcomes were reviewed for these patients.

RESULTS

A total of 896 primary CC ligament repairs or reconstructions were performed during the study period. There were 21 postoperative fractures and 1 intraoperative fracture in 20 patients. Of these fractures, 12 involved the coracoid and 10 involved the clavicle. The overall incidence of fracture was 3.81 fractures per 1000 person-years. In 5 patients who sustained a fracture, bone tunnels were not drilled in the fractured bone during the index procedure. A total of 17 fractures were ultimately treated operatively, whereas 5 fractures had nonoperative management. Of the 16 active-duty servicemembers who sustained intraoperative or postoperative fractures, 11 were unable to return to full military duty after their fracture care.

CONCLUSION

Fracture of the distal clavicle or coracoid process after CC ligament repair or reconstruction is a rare but serious complication that can occur independent of bone tunnels created during the index procedure. Fractures associated with CC ligament procedures occurred at a rate of 2.46 per 100 cases. Most patients were ultimately treated surgically with open reduction and internal fixation or revision CC ligament reconstruction. Although the majority of patients with intraoperative or postoperative fractures regained full range of motion, complications such as anterior shoulder pain, AC joint asymmetry, and activity-related weakness were common sequelae resulting in physical limitations and separation from military service.

Comparison of clinical efficacy between arthroscopically assisted Tight-Rope technique and clavicular hook plate fixation in treating acute high-grade acromioclavicular joint separations

INTRODUCTION

The purpose of this study was to compare the results of arthroscopically assisted reduction of acute acromioclavicular (AC) joint separations with the Tight-Rope technique with results of clavicular hook plate fixation.

MATERIALS AND METHODS

The 28 patients with acute high-grade AC joint dislocation were treated with arthroscopic assisted fixation using the Tight-Rope system, the arthroscopic evaluation and treatment of glenohumeral lesions were performed before AC ligament reconstruction. Each Tight-Rope technique group patient was matched with three controls that underwent clavicular hook plate fixation, and preoperation and postoperative visual analogue scale (VAS) and functional recovery (Constant Score) of the shoulder joint was assessed,. Furthermore, the demographics and clinical characteristics were compared between the two groups.

RESULTS

All patients had clinical and radiological results available at 2 years or greater (mean: 34; range: 24-72 months), they were statistically significant improvement in the constant score and VAS score at the end of follow-up respectively (P < 0.001). Compared with the clavicular hook plate group, Tight-Rope system group patients were incurred significant statistically lower skin incision, hospitalization time and estimated blood loss (P < 0.001), and the constant score and VAS score at the end of follow-up was significantly higher in the Tight-Rope group (P < 0.001). Patients who underwent clavicular hook plate had a higher incidence of fixation failure [10 cases (11.9%) versus 2 cases (7.1%)] than those of the Tight-Rope system group.

CONCLUSIONS

The Tight-Rope technique is advantageous for treating these patients because it is a minimally invasive procedure with low complications and superior clinical outcomes.

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.