A New Coracoclavicular Guider for Minimally Invasive Anatomic Coracoclavicular Reconstruction with Two TightRope Systems in Acute Acromioclavicular Joint Dislocation

In Vivo Analysis of Acromioclavicular Kinematics and Distance During Multiplanar Humeral Elevation

BACKGROUND

Knowledge of acromioclavicular (AC) joint kinematics and distance may provide insight into the biomechanical function and development of new treatment methods. However, accurate data on in vivo AC kinematics and distance between the clavicle and acromion remain unknown.

PURPOSE/HYPOTHESIS

The purpose of this study was to investigate 3-dimensional AC kinematics and distance during arm elevation in abduction, scaption, and forward flexion in a healthy population. It was hypothesized that AC kinematics and distance would vary with the elevation angle and plane of the arm.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 19 shoulders of healthy participants were enrolled. AC kinematics and distance were investigated with a combined dual fluoroscopic imaging system and computed tomography. Rotation and translation of the AC joint were calculated. The AC distance was measured as the minimum distance between the medial border of the acromion and the articular surface of the distal clavicle (ASDC). The minimum distance point (MDP) ratio was defined as the length between the MDP and the posterior edge of the ASDC divided by the anterior-posterior length of the ASDC. AC kinematics and distance between different elevation planes and angles were compared.

RESULTS

Progressive internal rotation, upward rotation, and posterior tilt of the AC joint were observed in all elevation planes. The scapula rotated more upward relative to the clavicle in abduction than in scaption (P = .002) and flexion (P = .005). The arm elevation angle significantly affected translation of the AC joint. The acromion translated more laterally and more posteriorly in scaption than in abduction (P < .001). The AC distance decreased from the initial position to 75° in all planes and was significantly greater in flexion (P < .001). The MDP ratio significantly increased with the elevation angle (P < .001).

CONCLUSION

Progressive rotation and significant translation of the AC joint were observed in different elevation planes. The AC distance decreased with the elevation angle from the initial position to 75°. The minimum distance between the ASDC and the medial border of the acromion moved anteriorly as the shoulder elevation angle increased.

CLINICAL RELEVANCE

These results could serve as benchmark data for future studies aiming to improve the surgical treatment of AC joint abnormalities to restore optimal function.

An Accuracy Comparison of Minimally Invasive Transclavicular-Transcortical Drilling with Free-Hand, C-Shape and Assembly-Type Guide Device: An In Vitro Study

OBJECTIVES

Ensuring the accuracy of transclavicular-transcoracoid drilling in the anatomical reconstruction of the coracoclavicular ligament complex with minimally invasive incisions remains a major problem for inexperienced surgeons. The purpose of this study was to design an assembly guide device for transclavicular-transcoracoid drilling with minimally invasive incisions, to manufacture the finished product, and to compare its feasibility and accuracy with the existing C-shape guide devices and free-hand techniques.

METHODS

An assembly-type guide device was designed and produced using computer-aided design and three-dimensional printing. The specimen data of 54 human shoulders from 27 gross specimen (14 males and 13 females) treated by free-hand drilling, C-shape device drilling, and assembly-type guide device drilling from October 2018 to January 2021 were analyzed in a controlled laboratory study. Fifty-four human shoulder specimens were randomly assigned into free-hand (n = 18), C-shape (n = 18), and assembly (n = 18) groups by drawing lots for transclavicular-transcoracoid drilling by three inexperienced surgeons. After the drilling procedure was completed and the devices were removed, the operation outcomes were assessed and evaluated. Distances from the tunnel edge to the coracoid's medial (d_m ) and lateral (d_l ) edges, operation time, and tunnel location zones on the coracoid's inferior surface of all specimens in the three groups were measured to evaluate the surgical accuracy and efficiency.

RESULTS

All specimens in the three groups completed the drilling operation successfully and were correctly measured. The distance differences (d_d ) between d_m and d_l in the free-hand, C-shape, and assembly groups were 3.2 ± 1.8 mm, 1.8 ± 1.0 mm, 1.0 ± 0.8 mm, respectively. The d_d of the free-hand group was higher than that of the other two groups (p < 0.001). The tunnel exit points on the inferior coracoid surface located in undesired zones were six (33%), one (6%), and zero in the free-hand group, C-shape group, and assembly-type group, respectively (p = 0.012). The operation time in the free-hand, C-shape, and assembly groups were 198 ± 36 s, 256 ± 64 s, and 353 ± 88 s, respectively. The operation time of each group significantly differed from that of the others (p < 0.001).

CONCLUSION

The assembly-type devices may be the first choice for inexperienced surgeons while both the C shape devices and assembly-type guide devices achieved higher accuracy than free-hand techniques.

Clinical Outcomes of Arthroscopy-Assisted Modified Triple Endobutton Plate Fixation in Rockwood Type III Acute Acromioclavicular Joint Dislocation: A Retrospective Study

Objective

The common triple Endobutton plate (CTEP) fixation is a lengthy procedure that is associated with high failure rates. Therefore, we used arthroscopy to improve the Endobutton fixation method by shortening the duration of surgery and reducing operative complications. This study explored the safety and effectiveness of arthroscopy‐assisted modified triple Endobutton plate (MTEP) fixation in Rockwood type III managing acute acromioclavicular joint (ACJ) dislocation.

Methods

This was a retrospective single‐center study involving 73 patients with Rockwood type III acute ACJ dislocation treated between January 2016 and January 2021. The 73 patients were classified into three groups, the acromioclavicular hook plate (ACHP) group (22 cases), CTEP group (24 cases) and MTEP group (27 cases), based on the type of surgical treatment they received. Clinical outcome data from the patient records, including the Constant–Murley score (CMS), American Shoulder and Elbow Surgeons score (ASES) and University of California at Los Angeles shoulder rating scale score (UCLA), were retrospectively reviewed. The scores were assessed before surgery and at the third and twelfth month after surgery. The clavicle‐coracoid (CC) distance on the affected side was estimated from imaging scans taken before surgery, on the second day after surgery, and within the third and twelfth month after surgery. The student's t‐test was used to compare normally distributed data for independent samples, while homogeneity of variance test was used to compare normally distributed data among multiple groups. Non‐normally distributed data were compared using Mann–Whitney rank‐sum tests.

Results

There were no differences in age, gender, body mass index (BMI), dislocated side, trauma etiology, and duration of follow‐up among the three groups. There was also no significant difference in the duration of surgery between the ACHP and MTEP groups, although the duration in the two groups was shorter than in the CTEP group (P < 0.05). The duration of hospitalization for the MTEP group was significantly shorter than for the CTEP group which was in turn shorter than for the ACHP group (both P < 0.05). There was no significant difference in postoperative CMS, ASES, and UCLA scores between the CTEP and MTEP groups but the score for the two groups differed significantly from those of the ACHP group (all Ps < 0.05). In addition, there was no significant difference in CC distance among the three groups after surgery (P > 0.05).

Conclusion

Arthroscopic reconstruction of the coracoclavicular ligament using MTEP fixation to manage acute Rockwood type III ACJ dislocation is minimally invasive, and is associated with rapid functional recovery, few complications and satisfactory early clinical results.

Clinical and radiological outcomes of acute Rookwood type IIIB acromioclavicular joint dislocation: Mini-open tightrope technique versus hook plate

OBJECTIVE

Treatment of acute Rookwood type III AC joint dislocation is still controversially discussed. ISAKOS suggested to subdivide type III AC joint injuries into type IIIA (stable) and type IIIB (unstable). The aim of this study was to compare clinical and radiographic outcomes between hook plate fixation and mini-open tightrope for the treatment of acute Rookwood type IIIB acromioclavicular joint dislocation.

METHODS

We conducted a retrospective clinical study of 112 patients with acute Rookwood type IIIB acromioclavicular joint dislocation who were treated surgically using either mini-open TightRope or hook plate from 2013 to 2019. All patients were followed up for 12 months. Clinical outcomes were evaluated using Visual Analogue Scale (VAS) and the Constant-Murley Score (CMS). Radiological results were assessed with the coracoclavicular distance (CCD), the change in clavicular elevation (ΔCE) and horizontal translation.

RESULTS

The length of incision was significantly shorter in the mini-open TightRope group than that in hook plate group (6.62±0.60 vs. 2.58±0.43 p <0.001). Duration of surgery was significantly shorter in the mini-open TightRope group than that in hook plate group (30.12±6.65 vs. 53.33±12.03; p < 0.001). Total blood loss volume was significantly less in the mini-open TightRope group than in the hook plate group. (23.85±7.88 vs. 70.67±24.62, p < 0.001). VAS and CMS in mini-open TightRope group were better than that in hook plate group at 2 weeks after surgery (VAS: 2.19±0.92 vs. 3.30±1.51, p = 0.002 and CMS 69.80±5.61 vs. 57.53±9.24, p<0.001) and 3 month after surgery (VAS: 1.19±0.48 vs. 3.07±1.36, p<0.001 and CMS 89.30±4.47 vs. 83.20±12.11, p = 0.205). There was no statistically significant difference between two groups at 12 months follow-up including VAS, CMS, the CC distance,ΔCE and the degree of dynamic horizontal translation. There were 2 complications in the hook plate group including 1cut out and 1 superficial wound infection.

CONCLUSION

The mini-open tightrope has better function and relieves pain in the early postoperative period compared to hook plate, and at the last follow up two groups have similar clinical and radiological outcomes. Mini-open TightRope fixation is a good option for the treatment of acute Rockwood types ⅢB AC joint dislocation.

Efficacy of Transosseous Tunnel Placement for Triple Endobutton Plate in Acromioclavicular Joint Reconstruction: A Three-Dimensional Printing Guide Design Technology

Objective

Explore an accurate transosseous tunnel drilling method based on three‐dimensional (3D) printing technology for acromioclavicular joint reconstruction (ACD), design a guide design, and evaluate its accuracy.

Methods

Using Mimics software to reconstruct 100 cases of acromioclavicular joint computed tomography (CT) data. In design 2, the non‐collinear tunnel is superimposed on the 3D model, and a virtual drilling is performed between the clavicle and the coracoid using a triple inner gusset. Then, in the Geomagic Studio software model, an elliptical plane is calculated and extracted as a guide design for precise drilling. Then put the design and the 3D shoulder model together for 3D printing. Ten lengths were measured, and the effects of the virtual model, the actual model, and the guide rail design were compared.

Results

We successfully compared 10 parameters of 3D virtual model and actual model. There was no significant difference between actual and virtual bone tunnels in 10 measurements (P > 0.05).

Conclusions

The accuracy of ACD combined with 3D printing guidance design technology in the transosseous tunnel of adult shoulder is reliable.

Comparison of single versus double TightRope system in the treatment of acute acromioclavicular joint dislocation

BACKGROUND

Reconstruction of the coracoclavicular (CC) ligament using a single TightRope (ST) system has some complications. We attempted to use a double TightRope (DT) system to reduce complications and obtain the ideal therapeutic effect.

PURPOSE

This investigation aimed to compare the ST and DT systems in terms of efficacy and safety in treating acromioclavicular (AC) joint dislocation.

METHODS

Sixty-six cases of acute AC joint dislocation between January 2013 and January 2018 were retrospectively reviewed. All patients were divided into 2 groups based on treatment with the ST or DT system. Patients were evaluated radiologically and clinically using the Disability of Arm, Shoulder, and Hand, Constant, and visual analog scale scores as clinical outcome measures at 1 day, 3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. The CC distance and displacement ratio were assessed radiologically.

RESULTS

The mean follow-up period was 49 months. Satisfactory clinical outcomes were obtained after CC fixation in both groups. No intergroup difference was found regarding the visual analog scale (P = .80), Disability of Arm, Shoulder, and Hand (P = .42), or Constant score (P = .28) at 2 years. However, there was a significant difference in the displacement ratio at 6 weeks (P < .0001), 3 months (P < .0001), 6 months (P < .0001), 1 year (P < .0001), and 2 years (P < .0001) postoperatively between the 2 groups. There were 3 complications in the ST group, including 1 case of secondary coracoid fracture, 1 case of AC joint arthrosis combined with ossification of the CC ligaments, and 1 case of clavicular erosion. All complications occurred in the ST group.

CONCLUSIONS

Both surgical methods are effective in treating AC joint dislocation, but the DT system is more reliable for reduction maintenance.

Biologic and synthetic ligament reconstructions achieve better functional scores compared to osteosynthesis in the treatment of acute acromioclavicular joint dislocation

PURPOSE

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

METHODS

Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of acute 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

One hundred and thirty-three studies were included for a total of 4473 shoulders. Mean age of participants was 36.9 years. Mean follow-up was 42.06 months. Arthroscopy showed better ASES (p < 0.0001) and lower VAS pain score (p = 0.0249) compared to an open approach. Biologic and synthetic reconstructions demonstrated better results over osteosynthesis techniques. Biologic techniques showed overall better Constant (p = 0.0001) and DASH (p = 0.0215) scores, while synthetic reconstruction showed better UCLA score (p = 0.0001). Among suture buttons, triple button showed overall better results in Constant (p = 0.0001) and VAS (p = 0.0001) scores, while better results in DASH score (p = 0.0003) were achieved by 2 double button techniques. Overall, the level of evidence was low.

CONCLUSION

Biological and synthetic reconstructions achieved better functional scores compared to osteosynthesis. Among suture buttons, the triple button showed better functional performance.

LEVEL OF EVIDENCE

IV.