Salvage of failed acromioclavicular joint reconstruction using autogenous semitendinosus tendon from the knee. Surgical technique and case report

Management of Acromioclavicular Joint Injuries: A Historic Account

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

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.

Current concepts in acromioclavicular joint (AC) instability - a proposed treatment algorithm for acute and chronic AC-joint surgery

BACKGROUND

There exists a vast number of surgical treatment options for acromioclavicular (AC) joint injuries, and the current literature has yet to determine an equivocally superior treatment. AC joint repair has a long history and dates back to the beginning of the twentieth century.

MAIN BODY

Since then, over 150 different techniques have been described, covering open and closed techniques. Low grade injuries such as Type I-II according to the modified Rockwood classification should be treated conservatively, while high-grade injuries (types IV-VI) may be indicated for operative treatment. However, controversy exists if operative treatment is superior to nonoperative treatment, especially in grade III injuries, as functional impairment due to scapular dyskinesia or chronic pain remains concerning following non-operative treatment. Patients with a stable AC joint without overriding of the clavicle and without significant scapular dysfunction (Type IIIA) may benefit from non-interventional approaches, in contrast to patients with overriding of the clavicle and therapy-resistant scapular dysfunction (Type IIIB). If these patients are considered non-responders to a conservative approach, an anatomic AC joint reconstruction using a hybrid technique should be considered. In chronic AC joint injuries, surgery is indicated after failed nonoperative treatment of 3 to 6 months. Anatomic AC joint reconstruction techniques along with biologic augmentation (e.g. Hybrid techniques, suture fixation) should be considered for chronic high-grade instabilities, accounting for the lack of intrinsic healing and scar-forming potential of the ligamentous tissue in the chronic setting. However, complication and clinical failure rates remain high, which may be a result of technical failures or persistent horizontal and rotational instability.

CONCLUSION

Future research should focus on addressing horizontal and rotational instability, to restore native physiological and biomechanical properties of the AC joint.

Qualitative and Quantitative Anatomic Descriptions of the Coracoclavicular and Acromioclavicular Ligaments: A Systematic Review

Purpose

Methods

Results

Conclusions

Clinical Relevance

Clinical and Patient-Reported Outcomes for Acute Acromioclavicular Joint Fixation are Similar With or Without Allograft Augmentation

Purpose

Methods

Results

Conclusion

Level of Evidence

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.

Transfer of the coracoid and conjoined tendon for failed, unstable, short clavicle following excessive outer clavicle resection

Nineteen patients presented with an unsightly deformity of the shoulder, pain or discomfort at the medial scapular border, pseudo nonparalytic scapular winging, and thoracic outlet symptoms after excessive resection of the clavicle for either complete acromioclavicular separation or displaced fracture of the outer clavicle, which allows the scapula and shoulder to rotate anteriorly and inferiorly on the chest creating traction on the medial scapular muscles and the brachial plexus resulting in pseudo nonparalytic winging and thoracic outlet symptoms. RESULTS: All underwent transfer of the coracoid process with the attached conjoined tendon to the end of the clavicle, restoring length and alignment. Eighteen patients were evaluated at a mean of 13.3 years. Seventeen had resolution of symptoms, restored alignment of the clavicle with the shoulder, improved appearance, healed transfer, and were pleased with the outcome. One patient was lost to follow-up but was considered a failure at his last visit. In a second patient, the transfer healed in a tilted position and the patient was dissatisfied with the appearance but otherwise had resolution of his symptoms. The mean American Shoulder and Elbow Surgeons Outcome Score improved from 53.2 preoperatively to 87.4 postoperatively (P < .02). CONCLUSION: This is the first report of using this transfer to restore length and alignment of an excessively short, unstable clavicle. The transfer succeeded in improving the appearance and symptoms in this complication of an excessively short, unstable clavicle.

Combination of Clavicular Hook Plate with Coracoacromial Ligament Transposition in Treatment of Acromioclavicular Joint Dislocation

OBJECTIVE

To evaluate the clinical efficacy of Arbeitsgemeinschaft für Osteosynthesefragen (AO) clavicular hook plate (CHP) combined with coracoacromial ligament transposition for Rockwood III-V dislocation of AC joint, providing an alternative choice for AC joint dislocation treatment.

METHODS

Twenty-five patients diagnosed with Rockwood III-V dislocation of acromioclavicular (AC) joint, including 18 males and seven females, aged 43.5 ± 2.4 years old on average, who had undergone open reduction and AO CHP in combination with coracoacromial (CC) ligament transposition between January 2010 and December 2015, were retrospectively analyzed. Among them, 17 cases were diagnosed as type III, five cases were type IV, and three cases were type V. The surgery mainly included three main steps: bone flap incision, drilling in the clavicle, and hook plate fixation and AC joint reposition. The treatment efficacy was evaluated through clinical examinations and imaging studies for the shoulder joint, including gross observation and measuring coracoid clavicle distance (CC-Dist) using orthophoria X-ray before and 1 year after the surgery, and University of California (UCLA) shoulder rating scale.

RESULTS

All the patients were followed up three to four times in 18 months (12-24 months) on average, and the UCLA rating results showed that there were 17 excellent cases (68%), five good cases (20%), and three fair cases (12%). The CC-Dist values after the surgery reduced to 9.7 ± 0.7 mm, which was significantly (P < 0.05) lower compared to that before the surgery (15.8 ± 1.6 mm). Most (88%) of the cases showed almost normal joint function and good anatomical arrangement of the acromioclavicular joint, without any secondary dislocation, and for them, 12 ± 2 weeks on average were needed to regain the normal function of shoulder joint movement.

CONCLUSION

Due to the stable fixation, fewer complications, and satisfactory therapeutic effect with great clinical value, the combination of AO CHP and CC ligament transposition is expected to be used for treating Rockwood III-V dislocation of AC joint.

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.

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.

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

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

Comparison of two methods for coracoclavicular ligament reconstruction: A finite element analysis

OBJECTIVE

This study aimed to compare two different tendon grafting techniques for coracoclavicular ligament reconstruction from the data obtained using finite element analysis.

METHODS

Three different finite element models of the shoulder girdle were formulated using computerized tomography images: the reference model, coracoid loop technique (CLT), and drilling technique (DT) model. In all these models, forces were applied to the clavicle along three axes (x, y, and z) of the trapezius and sternocleidomastoid muscles. Thereafter, data regarding the loading values of the tendon grafts, loads on the coracoid base, and coracoclavicular vertical distance were measured.

RESULTS

While the reference model yielded the lowest values for all the loading conditions as well as the shortest coracoclavicular distance, the DT model demonstrated the highest values for all the loading conditions and the largest coracoclavicular distance.

CONCLUSION

Different tendon grafting techniques may offer different loading values on both bone surface and tendon graft during coracoclavicular ligament reconstruction. The drilling technique may be associated with increased loading on the tendon graft and bone surface, causing further loss of reduction and consequent complications.

Sex-Based Differences in Optimal Tunnel Placement for Acromioclavicular Joint Reconstruction

BACKGROUND

Tunnel placement is important for outcomes after acromioclavicular (AC) joint reconstruction, yet little has been written on sex-based differences in optimal tunnel positioning.

HYPOTHESIS

No sex-based or anatomic differences will be found in ideal tunnel position based on radiographic measurements.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The records of 2382 patients were retrospectively examined for clavicle radiographs over a 20-year period. A random set of radiographs were reviewed until 200 radiographs from each sex met inclusion criteria per a priori power analysis. Anteroposterior clavicle radiographs were used to collect (1) length from lateral clavicle to lateral coracoid (LCLC), (2) length from lateral clavicle to medial coracoid (LCMC), (3) clavicle length (CL), and (4) clavicular depth at the midcoracoid (MCCD). The Student t test was used to compare differences between male and female patients. The Pearson correlation coefficient was used to measure linear correlations. Variables with a P < .1 were included in a multiple regression model.

RESULTS

The cohort included 200 men and 200 women. LCLC and LCMC were significantly greater for men than for women (P < .0001). Clavicle length was significantly correlated with LCLC (r = 0.63; P < .0001) and LCMC (r = 0.74; P < .0001). MCCD was significantly correlated with LCLC (r = 0.32; P < .0001) and LCMC (r = 0.43; P < .0001). The approximate placement for the trapezoid tunnel was found to be 22.1 mm in women and 26.6 mm in men. The approximate placement for the conoid tunnel was found to be 40 mm in women and 46.6 mm in men. The ratios (LCLC:CL and LCMC:CL) were also significantly different between female and male patients. The LCLC:CL was 0.144 in women and 0.154 in men (P < .0001). The LCMC:CL was 0.261 in women and 0.271 in men (P < .0006).

CONCLUSION

Significant sex-based differences are found in the position of the coracoid relative to the lateral edge of the clavicle. Coracoid position relative to the lateral edge of the clavicle is correlated with anatomic parameters, most strongly with clavicle length.

Acromioclavicular Joint Injuries: Evidence-based Treatment

Injuries to the acromioclavicular (AC) joint are common in the athletic patient population. Most AC joint injuries occur in young males, typically from a direct fall onto the superior aspect of the shoulder when the arm is adducted. Numerous publications describing joint anatomy and biomechanics, surgical techniques for reconstruction, and rehabilitation protocols are available to guide treatment strategies for injuries to the AC joint. Treatment is typically nonsurgical for type I and II injuries and surgical for type IV and VI injuries. Controversy surrounds the indications for nonsurgical versus surgical treatment of type III and V injuries. Multiple surgical techniques have been described, including coracoclavicular (CC) screw fixation, coracoacromial ligament transfer, and numerous methods of CC ligament reconstruction. Anatomic CC ligament reconstruction can be performed either open or arthroscopically, with and without graft augmentation. This article will discuss clinically relevant anatomy and biomechanical properties of the AC joint and will review decision-making principles and treatment options for common AC joint injuries. An updated summary of clinical outcomes after AC joint treatment will also be presented.

Current concepts in management of ACJ injuries

Acromioclavicular joint injury is common in young individuals who suffer direct trauma to the shoulder. Treatment of acromioclavicular dislocation is controversial with regards to the indication of operative management, timing of surgery, whether to perform open or arthroscopic surgery, method of stabilisation (rigid or non-rigid) and type of graft used for repair or reconstruction. Current evidence supports conservative management for Rockwood types I and II, while types IV, V and VI benefit from surgery. The optimal management of type III injuries in high demand patients remains contentious. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Few studies with a low level of evidence suggest arthroscopic techniques and anatomical ligament reconstruction have better outcomes when compared to older techniques of rigid coracoclavicular fixation. The aim of this article is to look at the current evidence and address these controversial issues.

A prospective study of coracoclavicular ligament reconstruction with autogenous peroneus longus tendon for acromioclavicular joint dislocations

BACKGROUND

Anatomic coracoclavicular (CC) ligament reconstruction (ACCR) provides good outcomes for Rockwood type III and VI acromioclavicular (AC) joint dislocations. Various grafts have been used, but complications from graft harvesting are not uncommon. This study examined the clinical and radiographic outcomes of patients with AC joint dislocations repaired with the autogenous anterior half of the peroneus longus tendon (AHPLT) to achieve ACCR.

METHODS

Patients with a Rockwood type III to V AC joint dislocation and magnetic resonance imaging of the disruption of the CC ligaments, as well as the AC capsule, were prospectively recruited. Patients received ACCR using an autogenous AHPLT graft and were evaluated clinically and radiographically preoperatively and at 1, 3, 6, and 12 months postoperatively.

RESULTS

A total of 18 patients (mean age, 51 years) were prospectively recruited and received an autogenous AHPLT graft ACCR. Fifteen patients completed clinical and radiographic follow-up examinations at 12 months. The mean Constant score (CS) was 51 preoperatively and 93 at 12 months (P <.005). No significant difference was noted at 12 months between the CS of the injured and contralateral shoulder. The mean American Orthopedic Foot and Ankle Society score at 12 months was 99, and this was not different from the value at any other time point. Loss of reduction occurred in 10 patients (56%), and tunnel widening was observed in 9 (50%), but neither was significantly correlated with functional outcome.

CONCLUSION

Autogenous AHPLT appears to be a reliable tendon graft source for CC ligament reconstruction.

Clinical efficacies of coracoclavicular ligament reconstruction using suture anchor versus hook plate in the treatment of distal clavicle fracture

INTRODUCTION

Comparison of clinical efficacies between coracoclavicular ligament reconstruction using autologous gracilis tendon with suture anchor and clavicular hook plate for the treatment of acute Neer type II distal clavicle fracture.

HYPOTHESIS

Both coracoclavicular reconstruction with autologous gracilis tendon and clavicular hook plate could achieve satisfactory results for treating acute Neer type II distal clavicle fracture.

METHODS

Acute Neer type II distal clavicle fracture patients enrolled in this prospective randomized study were divided into the coracoclavicular ligament reconstruction group (using autologous gracilis tendon and suture anchor) and the hook plate group. Clinical outcomes were evaluated by shoulder X-ray, forward flexion, abduction and external rotation angle, Constant-Murley shoulder score and pain Visual Analogue Scale (VAS) at each follow-up for up to 24 months.

RESULTS

The current study enrolled a total of 42 acute Neer type II distal clavicle fracture patients attended our hospital from March 2010 to December 2013. All patients had achieved complete healing and followed up for an average of 26 months (range, 24-38 months). At 3-month and 6-month follow-ups, Constant-Murley score in the ligament reconstruction group was significantly higher (93.8±2.6 vs. 88.7±8.7; 95.9±2.7 vs. 93.0±7.0, P<0.05), while VAS score was poorer than those in the hook plate group (1.6±0.8 vs. 2.5±1.9; 1.1±1.0 vs. 1.6±1.7, P<0.05).

DISCUSSION

Reconstruction with autologous gracilis tendon improved VAS pain score in early postoperation follow-up; while Constant-Murley score and VAS score were significantly improved in the hook plate group after the implant was removed. These suggested that both coracoclavicular reconstruction with autologous gracilis tendon and clavicular hook plate could achieve satisfactory results.

LEVEL OF EVIDENCE

Level II, low-powered prospective randomized trial.

Study on the anatomic relationship between the clavicle and the coracoid process using computed tomography scans of the shoulder

BACKGROUND

The current trend in the treatment of acromioclavicular dislocations is to reconstruct the coracoclavicular ligaments by using transosseous tunnels in the coracoid process or in the clavicle, yet there is no definition as to the location of these. To study the anatomic relationship between the coracoid process and the clavicle, we made measurements to find a convergence point (cP) between them that has intraoperative applicability for creating transosseous tunnels.

METHODS

We analyzed 74 computed tomography scans (40 female and 34 male patients). Measurements were taken in the axial and sagittal planes and obtained from a cP, as determined by the intersection of the cortical surface of the clavicle and the coracoid process, with various relationships having been established.

RESULTS

On average, the cP was determined to be about 2.9 cm and 2.5 cm distant from the coracoid process apex for male and female patients, respectively, whereas the width at this position was determined to be 2.1 cm and 1.9 cm. In the clavicle, this point is on average 2.9 cm and 2.5 cm distant from the acromioclavicular joint in male and female patients, respectively, and its anteroposterior width at this point is on average 1.9 cm and 1.6 cm.

CONCLUSION

The cP of the clavicle and the coracoid process was determined with the aim of preparing bone tunnels in operations for treating acromioclavicular dislocations.

Shoulder acromioclavicular joint reconstruction options and outcomes

Acromioclavicular joint separations are a common cause of shoulder pain in the young athletic population. In high-grade injuries, acromioclavicular joint reconstruction procedures may be indicated for functional improvement. There is currently no gold standard for the surgical management of these injuries. Multiple reconstructive options exist, including coracoclavicular screws, hook plates, endobutton coracoclavicular fixations, and anatomic ligament reconstructions with tendon grafts. This article aims to review pertinent acromioclavicular joint anatomy and biomechanics, radiographic evaluation, classification system, as well as reconstruction options, outcomes, and complications.

Modified Weaver-Dunn Procedure Versus The Use of Semitendinosus Autogenous Tendon Graft for Acromioclavicular Joint Reconstruction

Background:

The optimal operative method for acromioclavicular joint reconstruction remains controversial. The modified Weaver-Dunn method is one of the most popular methods. Anatomic reconstruction of coracoclavicular ligaments with autogenous tendon grafts, widely used in treating chronic acromioclavicular joint instability, reportedly diminishes pain, eliminates sequelae, and improves function as well as strength.

Objective:

To compare clinical and radiologic outcomes between a modified Weaver-Dunn procedure and an anatomic coracoclavicular ligaments reconstruction technique using autogenous semitendinosus tendon graft.

Methods:

Twenty patients (mean age, 39 years) with painful, chronic Rockwood type III acromioclavicular joint dislocations were subjected to surgical reconstruction. In ten patients, a modified Weaver-Dunn procedure was performed, in the other ten patients; autogenous semitendinosus tendon graft was used. The mean time between injury and the index procedure was 18 month (range from 9 – 28). Clinical evaluation was performed using the Oxford Shoulder Score and Nottingham Clavicle Score after a mean follow-up time of 27.8 months. Preoperative and postoperative radiographs were compared.

Results:

In the Weaver-Dunn group the Oxford Shoulder Score improved from 25±4 to 40±2 points. While the Nottingham Clavicle Score increased from 48±7 to 84±11. In semitendinosus tendon graft group, the Oxford Shoulder Score improved from 25±3 points to 50±2 points and the Nottingham Clavicle Score from 48±8 points to 95±8, respectively.

Conclusion:

Acromioclavicular joint reconstruction using the semitendinosus tendon graft achieved better Oxford Shoulder Score and Nottingham Clavicle Score compared to the modified Weaver-Dunn procedure.

Two-Year Outcomes After Primary Anatomic Coracoclavicular Ligament Reconstruction

PURPOSE

The purpose of this study was to report the clinical and structural outcomes after anatomic coracoclavicular ligament reconstruction (ACCR) with free tendon allografts in patients with grade III and grade V acromioclavicular (AC) joint dislocations.

METHODS

Thirty-one shoulders underwent primary ACCR with tendon allografts for Rockwood grade III and grade V AC joint dislocations. Preoperative data included patient demographic characteristics, injury characteristics, and surgical history, along with American Shoulder and Elbow Surgeons (ASES) scores, Short Form 12 Physical Component Summary (SF-12 PCS) scores, and various pain scales. Outcome measures were also collected a minimum of 2 years postoperatively with the addition of Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; Single Assessment Numeric Evaluation (SANE) scores; and patient satisfaction. In addition, preoperative and postoperative coracoclavicular distances were analyzed using standard anteroposterior radiographs.

RESULTS

ACCR was performed in 31 patients (31 shoulders) with a mean age of 43.9 years (range, 21 to 71 years). In 7 patients (22.6%) a complication occurred that required a subsequent surgical procedure including graft rupture/attenuation (2), clavicle fractures (2), distal clavicle hypertrophy (2), and adhesive capsulitis (1). Of the remaining 24 patients, 20 (83.3%) had subjective outcome data available after a minimum 2-year follow-up period (mean, 3.5 years; range, 2.0 to 6.2 years). The mean postoperative ASES and SF-12 PCS scores significantly improved when compared with the preoperative baseline values (58.9 v 93.8 for ASES scores [P < .001] and 45.3 v 54.4 for SF-12 PCS scores [P = .007]). At final follow-up, the SANE and QuickDASH scores were 89.1 and 5.6, respectively, with a median patient satisfaction rating of 9 of 10.

CONCLUSIONS

Patients who did not require revision surgery showed excellent postoperative outcome scores: The mean ASES score was 93.8, the mean SANE score was 89.1, and the mean QuickDASH score was 5.6, with a median patient satisfaction rating of 9 of 10. Further study regarding ACCR techniques should focus on decreasing the risks of complications and maintaining reduction of the AC joint.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Anatomical Double-Bundle Coracoclavicular Reconstruction in Chronic Acromioclavicular Dislocation

The purpose of this study was to evaluate the clinical and radiological outcomes of anatomical double-bundle coracoclavicular (CC) reconstruction using the coracoacromial (CA) ligament and the conjoined tendon for the treatment of chronic acromioclavicular (AC) joint dislocation. A retrospective evaluation was performed on 18 patients who underwent an anatomical CC reconstruction using the CA ligament and the conjoined tendon for chronic AC joint dislocation. Patients were treated surgically between April 2007 and January 2012. Mean follow-up was 35.3 months (range, 24-49 months). All patients were evaluated for functional outcomes using the modified University of California, Los Angeles (UCLA) shoulder rating scale for chronic AC injury and the Constant-Murley shoulder outcome score. Range of motion and shoulder and elbow strength were also measured. Plain radiographs were taken to evaluate reduction status and CC distance. Mean modified UCLA shoulder rating scale at final follow-up was 18.1 points (range, 13-20 points). No significant difference in mean Constant-Murley scores existed between the injured and contralateral shoulders (P=.26). At final follow-up, 15 (83.3%) patients had well-maintained reduction and 2 (11.1%) patients had a partial loss of reduction. One other patient had a complete loss of reduction due to a postoperative fall. The CC distance was not significantly different between the injured and contralateral shoulders in the immediate postoperative period (P=.46) or at final follow-up (P=.14). One superficial wound infection occurred and was treated with routine wound care. An anatomical double-bundle CC reconstruction using the CA ligament and the conjoined tendon for the treatment of chronic AC joint dislocation is a reliable surgical method with good results.

Vascular graft employment in the surgical treatment of acute and chronic acromio-clavicular dislocation

OBJECTIVES

To show the efficiency and safety of a surgical treatment in both acute and chronic acromio-clavicular junction (ACJ) dislocations.

DESIGN

Retrospective.

SETTING

Department of Orthopedics and Traumatology at IRCCS San Raffaele Hospital.

PATIENTS/PARTICIPANTS

This study was performed on 37 subjects classified as Rockwood grade III-V or Tossy III ACJ dislocation.

PROCEDURE

The surgical treatment was carried out by placing a vascular graft (GorePropaten(®)) between the tip of the coracoid process and the mid-lateral side of the clavicle with two temporary percutaneous K-wires positioned in a parallel manner in the AC ligament through the acromion and clavicle for 30 days to improve stability.

MAIN OUTCOME MEASUREMENTS

Outcomes were assessed using the Constant Shoulder (CS) score, DASH score, subjective satisfaction, and stability of AC joint at 24 months. UCLA scores taken preoperatively and at 15-month follow-up were used to perform statistical analysis significance using a control group treated conservatively. Postoperative X-rays were examined to assess joint stability after 24 months.

RESULTS

Preoperative CS score was 51 ± 12 in the acute group and 55 ± 15 in the chronic group. Follow-up mean CS score was 88 ± 11 in the acute group and 82 ± 20 in the chronic group at 24 months. Preoperative DASH score was 19 ± 3 in the acute group and 14 ± 5 in the chronic group. Mean DASH score was 3.60 ± 7 in the acute group and 6.42 ± 6 in the chronic group. Preoperative UCLA scores were 14.6 ± 2 and 15 ± 7 in the acute group and chronic group, respectively. At 15-month follow-up, UCLA scores of 28.1 ± 1.9 and 27.7 ± 1 in the acute and chronic group, respectively, showed a significant improvement (p < 0.05) compared with UCLA scores taken preoperatively and at 15 months in the control group treated conservatively of 15.8 ± 0.9 and 16.2 ± 0.9, respectively. Results were good to excellent in 10 patients from the acute group and 23 patients from the chronic group who presented clinical stability of the AC joint without pain. Postoperative radiography showed anatomical repositioning of the ACJ and joint stability in 35 cases, but only two patients showed a partial re-dislocation at the 24-month X-ray follow-up. No infections, either deep or superficial, or nerve palsies were reported.

CONCLUSIONS

Given the results obtained during the study and the response of the patients in both acute and chronic groups, the authors found that the employment of a vascular graft combined with temporary percutaneous K-wires is able to improve the patient's clinical outcome following an acromio-clavicular joint dislocation.

Comparison of results between hook plate fixation and ligament reconstruction for acute unstable acromioclavicular joint dislocation

Background

In the present study, we aimed to compare clinical and radiographic outcomes between hook plate fixation and coracoclavicular (CC) ligament reconstruction for the treatment of acute unstable acromioclavicular (AC) joint dislocation.

Methods

Forty-two patients who underwent surgery for an unstable acute dislocation of the AC joint were included. We divided them into two groups according to the treatment modality: internal fixation with a hook plate (group I, 24 cases) or CC ligament reconstruction (group II, 18 cases). We evaluated the clinical outcomes using a visual analog scale (VAS) for pain and Constant-Murley score, and assessed the radiographic outcomes based on the reduction and loss of CC distance on preoperative, postoperative, and final follow-up plain radiographs.

Results

The mean VAS scores at the final follow-up were 1.6 ± 1.5 and 1.3 ± 1.3 in groups I and II, respectively, which were not significantly different. The mean Constant-Murley scores were 90.2 ± 9.9 and 89.2 ± 3.5 in groups I and II, respectively, which were also not significantly different. The AC joints were well reduced in both groups, whereas CC distance improved from a mean of 215.7% ± 50.9% preoperatively to 106.1% ± 10.2% at the final follow-up in group I, and from 239.9% ± 59.2% preoperatively to 133.6% ± 36.7% at the final follow-up in group II. The improvement in group I was significantly superior to that in group II (p < 0.001). Furthermore, subluxation was not observed in any case in group I, but was noted in six cases (33%) in group II. Erosions of the acromion undersurface were observed in 9 cases in group I.

Conclusions

In cases of acute unstable AC joint dislocation, hook plate fixation and CC ligament reconstruction yield comparable satisfactory clinical outcomes. However, radiographic outcomes based on the maintenance of reduction indicate that hook plate fixation is a better treatment option.

Acromioclavicular third degree dislocation: surgical treatment in acute cases

Background

The management of acute Rockwood type III acromioclavicular joint (ACJ) dislocation remains controversial, and the debate about whether patients should be conservatively or surgically treated continues. This study aims to compare conservative and surgical treatment of acute type III ACJ injuries in active sport participants (<35 years of age) by analysing clinical and radiological results after a minimum of 24 months follow-up.

Methods

The records of 72 patients with acute type III ACJ dislocations who were treated from January 2006 to December 2011 were retrospectively evaluated. Patients were categorised into two groups. group A included 25 patients treated conservatively, and group B included 30 patients treated surgically with the TightRope™ system. Seventeen patients were lost to follow-up.

All patients were evaluated at final follow-up with these clinical scores: Constant, University of California Los Angeles scale (UCLA), American Shoulder and Elbow Surgeons Scale (ASES) and Acromioclavicular Joint Instability (ACJI) and with a subjective evaluation of the patient satisfaction, aesthetic results and shoulder function. The distance between the acromion and clavicle and between the coracoid process and clavicle were evaluated radiographically and compared with preoperative values. Δ, the difference in mm between the distance at the final follow-up and at T0 in the injured shoulder, and α, the side-to-side difference in mm at follow-up, were calculated. Heterotopic ossification and postoperative osteolysis were evaluated in both groups.

Results

There were no major intraoperative complications in the surgical group. The subjective parameters significantly differed between the two groups. Constant, ASES and UCLA scores were similar in both groups (P > 0.05), whereas ACJI results favoured the surgical group (group A, 72.4; group B, 87.9; P < 0.05). All measurements of radiographic evaluation were significantly reduced in the surgical group compared with the conservative group. In group A, we detected calcifications in 30% of patients; in group B we detected two cases of moderate osteolysis and calcifications in 70% of patients.

Conclusion

Although better subjective and radiographic results were achieved in surgically treated patients, traditional objective scores did not show significant differences between the two groups. Our results cannot support routine use of surgery to treat type III ACJ dislocations.

Coracoclavicular ligament reconstruction: a systematic review and a biomechanical study of a triple endobutton technique

Operative intervention is recommended for complete acromioclavicular (AC) joint dislocation to restore AC stability, but the best operative technique is still controversial. Twelve fresh-frozen male cadaveric shoulders (average age, 62.8±7.8 years) were equally divided into endobutton versus the modified Weaver-Dunn groups. Each potted scapula and clavicle was fixed in a custom made jig to allow translation and load to failure testing using a Zwick BZ2.5/TS1S material testing machine (Zwick/Roell Co, Germany). A systematic review of 21 studies evaluating reconstructive methods for coracoclavicular or AC joints using a cadaveric model was also performed. From our biomechanical study, after ligament reconstruction, the triple endobutton technique demonstrated superior, anterior, and posterior displacements similar to that of the intact state (P>0.05). In the modified Weaver-Dunn reconstruction group, however, there was significantly greater anterior (P<0.001) and posterior (P=0.003) translation after ligament reconstruction. In addition, there was no significant difference after reconstruction between failure load of the triple endobutton group and that of the intact state (686.88 vs 684.9 N, P>0.05), whereas the failure load after the modified Weaver-Dunn reconstruction was decreased compared with the intact state (171.64 vs 640.86 N, P<0.001). From our systematic review of 21 studies, which involved comparison of the modified Weaver-Dunn technique with other methods, the majority showed that the modified Weaver-Dunn procedure had significantly (P<.05) greater laxity than other methods including the endobutton technique. The triple endobutton reconstruction proved superior to the modified Weaver-Dunn technique in restoration of AC joint stability and strength. Triple endobutton reconstruction of the coracoclavicular ligament is superior to the modified Weaver-Dunn reconstruction in controlling both superior and anteroposterior displacements with a failure load that approximates the intact ligament.

Comparison of single and two-tunnel techniques during open treatment of acromioclavicular joint disruption

Background

Coracoclavicular (CC) ligament reconstruction with semitendinosus tendon (ST) grafts has become more popular and has achieved relatively good results; however optimal reconstruction technique, single-tunnel or two-tunnel, still remains controversial. This paper is to compare the clinical and radiographic data of allogenous ST grafting with single- or two-tunnel reconstruction techniques of the AC joint.

Methods

The outcomes of 21 consecutive patients who underwent anatomical reduction and ST grafting for AC joint separation were reviewed retrospectively. Patients were divided into two groups: single-tunnel group (11) and two-tunnel group (10). All patients were evaluated clinically and radiographically using a modified UCLA rating scale.

Results

The majority of separations (18 of 21) were Rockwood type V, with one each in type III, IV and VI categories. The overall mean follow-up time was 16 months, and at the time of the latest follow-up, the overall mean UCLA rating score was 14.1 (range 8–20).

The percentage of good-to-excellent outcomes was significantly higher for patients with the two-tunnel technique than for those with the one-tunnel technique (70% vs. 18%, respectively, p = 0.03). Within the single-tunnel group, there was no statistically significant difference in percentage of good-to-excellent outcomes between patients with vs. without tightrope augmentation (17% vs 20%, p > 0.99). Similarly, within the two-tunnel group, there was no significant difference in the percentage of good-to-excellent outcomes between the graft only and augment groups (67% vs. 75%, p > 0.99).

Conclusion

Anatomical reduction of the AC joint and reconstruction CC ligaments are crucial for optimal joint stability and function. Two-tunnel CC reconstruction with an allogenous ST graft provides superior significantly better radiographic and clinical results compared to the single-tunnel reconstruction technique.

Surgical treatment of chronic acromioclavicular joint dislocation with autogenous tendon grafts

Background

Conservative treatment of acromioclavicular (AC) joint dislocation is not always successful. A consequence of persistent AC joint dislocation may be chronic pain and discomfort in the shoulder region as well a sensation of constant AC joint instability and impaired shoulder function. Stabilization of the AC joint may reduce these sequels.

Materials and methods

Due to chronic AC joint dislocation, 39 patients in our hospital underwent coracoclavicular (CC) ligament reconstruction with autogenous semitendinosus and gracilis tendons between May 2005 and April 2011. We examined 25 patients after a mean of 4.2 years. The outcomes were Constant shoulder Score (CS), Disabilities of the Arm, Shoulder and Hand (DASH), pain (Visual Analog Scale, VAS), cross-arm test, stability of the AC joint, and complications. The follow-up visits included anteroposterior and axillary radiographs.

Results

Mean CS was 83 in the injured shoulder and 91 in the uninjured shoulder (p = 0.002). Mean DASH was 14. In 14 patients, the AC joint was clinically stable; pain was minor. In radiographs, osteolysis of the lateral clavicle and tunnel widening were markedly common. Fracture of the coracoid process occurred in 5 patients, and 3 suffered a fracture of the clavicle; 2 had a postoperative infection.

Conclusions

Anatomic reconstruction of CC ligaments showed a moderate subjective outcome at the 4-year follow-up. After surgery, almost half the AC joints failed to stabilize. Lateral clavicle osteolysis and tunnel widening were notably common complications.

Surgical treatment of chronic acromioclavicular dislocation with biologic graft vs synthetic ligament: a prospective randomized comparative study

BACKGROUND

Acromioclavicular (AC) dislocation involves complete loss of articular contact; it is defined as chronic when it follows conservative management or unsuccessful surgical treatment.

MATERIALS AND METHODS

The study compared the clinical and radiographic outcomes of AC joint stabilization performed in 40 patients with chronic dislocation using a biological allograft (group A) or a synthetic ligament (group B). Demographic data included: M/F: 25/15; mean age: 35 ± 3.2 years; previous surgery in 11 patients, including Weaver-Dunn (3), coracoacromial ligament repair (4), stabilization with K-wires (4). Dislocation was type III in 14 (35 %) and type IV in 26 (65 %) patients. Clinical assessment was with the Constant-Murley score (pre- and postoperative) and with the modified UCLA score. Enrollment started in January 2004 and was completed in March 2008. Patients were evaluated at 1 and 4 years. Postoperative X-rays were examined to assess joint stability in the coronal and axial planes, coracoclavicular ossification, and signs of AC joint osteoarthritis and distal clavicular osteolysis.

RESULTS

The "biological" group achieved significantly better clinical scores than the "synthetic" group at both 1 and 4 years. Poor subjective satisfaction and lower clinical scores were found in the 3 patients (1 from group A and 2 from group B) who experienced complete postoperative dislocation. No significant correlations were found with other radiographic parameters.

CONCLUSIONS

The biological graft afforded better clinical and radiographic outcomes than the synthetic ligament in patients with chronic AC joint instability. Fixation to the clavicle constitutes the main weakness of both approaches and needs improving.

Impact of tunnels and tenodesis screws on clavicle fracture: a biomechanical study of varying coracoclavicular ligament reconstruction techniques

PURPOSE

The purpose of this study was to compare the load to fracture of distal clavicles with no tunnels, one tunnel, or 2 tunnels and to evaluate the effect of inserting tenodesis screws in the tunnels on load to fracture of the distal clavicle.

METHODS

Fifty right sawbone clavicles were obtained and divided into 5 groups (n = 10): group 1, normal clavicle; group 2, one tunnel, no tenodesis screw; group 3, 2 tunnels, no tenodesis screws; group 4, one tunnel with tenodesis screw; and group 5, 2 tunnels with 2 tenodesis screws. Tunnels were created using a 5-mm-diameter reamer, and 5.5 × 10 mm polyethyl ethyl ketone tenodesis screws were used. A 4-point bending load was applied to the distal clavicles. Load to failure was noted for each specimen.

RESULTS

Load to failure in clavicles without tunnels was significantly higher (1,157.18 ± 147.10 N) than in all other groups (P < .0005). No statistical differences were noted between groups 2, 3, 4, and 5. Load to failure was not statistically different in clavicles with one versus 2 tunnels. In addition, the use of tenodesis screws in the tunnels did not affect the load required to fracture.

CONCLUSIONS

The use of tunnels in the clavicle for coracoclavicular (CC) ligament reconstruction significantly reduces the load required to fracture the distal clavicle. The addition of tenodesis screws does not appear to significantly increase the strength of the clavicle in this construct.

CLINICAL RELEVANCE

CC ligament reconstruction techniques commonly use tunnels in the distal clavicle, which may render the clavicle more susceptible to fracture. This study helps quantify the effect of these tunnels on the strength of the distal clavicle.

Biomechanical evaluation of a novel reverse coracoacromial ligament reconstruction for acromioclavicular joint separation

BACKGROUND

Enhancing anterior-posterior (AP) stability in acromioclavicular (AC) reconstruction may be advantageous.

PURPOSE

To compare the initial stability of AC reconstructions with and without augmentation by either (1) a novel "reverse" coracoacromial (CA) ligament transfer or (2) an intramedullary AC tendon graft.

HYPOTHESIS

Reverse CA transfer will improve AP stability compared with isolated coracoclavicular (CC) reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Six matched pairs of cadaveric shoulders underwent distal clavicle resection and CC reconstruction. Displacement (mm) was measured during cyclic loading along AP (±25 N) and superior-inferior (SI; 10-N compression, 70-N tension) axes. Pairs were randomized to receive each augmentation and the same loading protocol applied.

RESULTS

Reverse CA transfer (3.71 ± 1.3 mm, standard error of the mean [SEM]; P = .03) and intramedullary graft (3.41 ± 1.1 mm; P = .03) decreased AP translation compared with CC reconstruction alone. The SI displacement did not differ. Equivalence tests suggest no difference between augmentations in AP or SI restraint.

CONCLUSION

Addition of either reverse CA transfer or intramedullary graft demonstrates improved AP restraint and provides similar SI stability compared with isolated CC reconstruction.

CLINICAL RELEVANCE

Reverse CA ligament transfer may be a reasonable alternative to a free tendon graft to augment AP restraint in AC reconstruction.

Biomechanical comparison of acromioclavicular joint reconstructions using coracoclavicular tendon grafts with and without coracoacromial ligament transfer

PURPOSE

The purpose of this study was to compare the initial strength of acromioclavicular joint reconstructions using coracoclavicular (CC) tendon grafts with and without coracoacromial (CA) ligament transfers.

METHODS

Two different acromioclavicular joint reconstructions were performed in 7 matched pairs of cadaveric shoulders. Paired shoulders were repaired with either a hamstring allograft CC reconstruction (group 1) or a hamstring allograft CC reconstruction plus a CA ligament transfer (group 2). Intact specimens and then reconstructions were cycled from 0 to 100 N at 1 Hz for 100 cycles in a superior direction, and displacements were recorded. Finally, the stiffness of the reconstructions and the ultimate load to failure were recorded.

RESULTS

Superior displacement of the reconstructions after cyclic loading was 4.43 ± 1.82 mm in group 1 and 3.75 ± 1.56 mm in group 2 (P = .38). Ultimate load after load to failure was 970.3 ± 361.03 N in group 1 and 952.7 ± 296.89 N in group 2 (P = .94). Finally, stiffness of the reconstructions was 50.6 ± 6.14 N/mm in group 1 and 65.6 ± 18.45 N/mm in group 2 (P = .12).

CONCLUSIONS

The addition of a transfer of the CA ligament to an acromioclavicular joint reconstruction with a CC hamstring graft does not appear to significantly improve its overall initial biomechanical strength.

CLINICAL RELEVANCE

These data suggest that a CA ligament transfer may add very little to a CC tendon graft reconstruction augmented with high-strength suture with regard to initial, time zero displacement and strength.

Reconstrução coracoclavicular com enxerto tendíneo na luxação acromioclavicular crônica

OBJETIVO: Apresentar os resultados radiográficos e funcionais de pacientes submetidos ao tratamento da luxação acromioclavicular crônica com reconstrução dos ligamentos coracoclaviculares com enxerto de tendão semitendíneo. MÉTODO: Quinze pacientes, entre abril de 2007 e junho de 2008, foram submetidos a reconstrução dos ligamentos coracoclaviculares com enxerto tendíneo. Dois pacientes foram excluídos do estudo por seguimento inadequado. Treze pacientes foram seguidos clinicamente e radiograficamente, em média, por 16 meses (12-26 meses). Os pacientes foram submetidos a avaliação clinica pré e pós-operatória, utilizando os escores Constant e UCLA. Radiografias pré e pós-operatórias foram comparadas. RESULTADOS: Neste grupo de 13 pacientes com seguimento mínimo de um ano, o escore Constant variou de 60,9 (26-88) na avaliação pré-operatória para 87 (60-98) na última avaliação no período pós-operatório. O escore UCLA foi de 16,8 (11-27) no pré operatório para 33 (29-35) na avaliação pós-operatória (p=0,001). No controle radiográfico com um ano de pós-operatório, encontramos 12 pacientes (92%) com a distância coracoclavicular igual comparando o ombro operado ao contralateral. Todos os ombros operados apresentavam-se sem translação na direção antero-posterior no perfil axilar. CONCLUSÃO: O resultado funcional e radiográfico foi muito satisfatório nos pacientes submetidos à reconstrução das luxações acromioclaviculares crônicas, com baixo indice de recidiva. Nivel de Evidência IV, série de casos.

Management of the failed AC joint reconstruction: causation and treatment

With recent studies showing improved biomechanical behavior of anatomic acromioclavicular joint reconstructions, these techniques are more frequently being performed. With both the more historic methods of fixation such as coracoacromial ligament transfer along with the newer anatomic reconstruction, potential for failure exists. However, there is a paucity of literature addressing these failures and possible treatment options. The purpose of this review is to report cases of failed reconstructions, describe failure mechanisms, and propose treatment options.

Clinical results of single-tunnel coracoclavicular ligament reconstruction using autogenous semitendinosus tendon

BACKGROUND

Over 60 repair/reconstruction techniques have been described for the treatment of coracoclavicular (CC) ligament injuries.

PURPOSE

To report the functional and radiological outcomes of single-tunnel CC ligament reconstruction using autogenous semitendinosus tendon.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between August 2005 and January 2008, a total of 21 patients, 16 patients (14 men, 2 women) with a Rockwood type IV, type V, or a chronic type III acromioclavicular (AC) dislocation and 5 patients (4 men, 1 woman) with a painful nonunited distal clavicle fracture with CC separation, underwent CC reconstructive surgery using a semitendinosus autograft. All 21 patients were followed up clinically and radiographically. The mean follow-up was 33 months (range, 18-47), and the mean patient age was 39.8 years (range, 18-70). Chronic type III AC dislocations and nonunited distal clavicle fractures with CC separation were scored using preoperative AC scoring (AC Joint Separation Questionnaire). Constant, University of California-Los Angeles (UCLA), and AC scores were evaluated for all patients at final follow-up.

RESULTS

At the final follow-up, 10 patients achieved an "excellent" result and 11 a "good" result according to the AC scoring scheme. Mean final Constant and UCLA scores were 84.7 (range, 67-94) and 30.0 (range, 23-35), respectively. In the antero-posterior (AP) plane, 17 (81%) of the 21 patients maintained complete reduction, and 1 of the remaining 4, a manual laborer, had complete reduction loss. Of the 17 patients with an axillary view at final follow-up, 1 patient (5.9%) showed partial subluxation, although no subluxation was observed in the AP radiograph. The other 16 patients (94.1%) had a complete reduction state in axillary view.

CONCLUSION

Single-tunnel CC reconstruction with an autogenous hamstring tendon graft after a mean follow-up of 33 months (range, 18-47) appears to be a satisfactory means of treating acute Rockwood type IV, V, chronic type III, and painful nonunited distal clavicle fractures with CC separation.

The anatomic coracoclavicular ligament reconstruction: surgical technique and indications

The anatomic coracoclavicular ligament reconstruction (ACCR) is a surgical procedure to address acriomioclavicular joint instability. The coracoclavicular ligaments are reconstructed using a semitendinosus allograft passed beneath the coracoid and through bone tunnels in the clavicle. The graft is secured with interference screw fixation, and the acromioclavicular joint is retained. Here we describe the authors' surgical technique, indications, and rehabilitation protocol. Also, a preliminary case series of seventeen patients is presented. Patients demonstrated significant improvement in pain levels and function. The mean ASES score increased from 52 preoperatively to 92. The Constant Murley rose from 66.6 to 94.7. There were three failures in this series, and two required revision surgery.

Failure of coracoclavicular artificial graft reconstructions from repetitive rotation

PURPOSE

To assess how suture type and suture construct in an augmented Weaver-Dunn reconstruction affect coracoclavicular sling failure and rotary stability.

METHODS

Fifteen cadaveric shoulders were tested in rotation about the long axis of the clavicle with 10 lb of simulated arm weight. The clavicle was rotated 50 degrees about its long axis, and the applied torque was recorded. Next, modified Weaver-Dunn reconstruction was conducted. Two types of coracoclavicular sling (opposed drill holes through the clavicle and complete loop around the clavicle) were tested by use of 3 different sutures (FiberWire [Arthrex, Naples, FL], Mersilene tape [Ethicon, Somerville, NJ], and braided polydioxanone [PDS] [Ethicon]). For each sling-suture combination, the joint was retested over 50 degrees of rotation and then cycled over 40 degrees of rotation for 15,000 cycles or until failure.

RESULTS

After modified Weaver-Dunn reconstruction with either sling construct, mean torque over 50 degrees of acromioclavicular rotation was significantly reduced in posterior (P < .0001) and anterior (P < .0001) rotation, with any suture material tested. When the coracoclavicular sling was placed through opposed drill holes, no wear to the bone or suture was observed. When the sling material was looped around the clavicle, FiberWire and PDS resulted in abrasion of soft tissue and periosteum. In all cases sawing motion between bone and suture was observed at the coracoid. The FiberWire itself failed at a mean of 8,213 cycles. Some wear was noted in the Mersilene tape. PDS suture showed no wear.

CONCLUSIONS

In a cadaveric model of modified Weaver-Dunn reconstruction, a coracoclavicular suture loop was used to augment coracoacromial ligament transfer. Suture loops secured around the entire clavicle were shown to contribute to increased abrasive wear. Securing suture loops through opposed drill holes in the clavicle resulted in decreased abrasive wear.

CLINICAL RELEVANCE

Proper selection of suture type and suture construct may affect the failure rate of augmented Weaver-Dunn reconstructions.

Acromioclavicular joint injuries: diagnosis and management

Acromioclavicular joint injuries represent nearly half of all athletic shoulder injuries, often resulting from a fall onto the tip of the shoulder with the arm in adduction. Stability of this joint depends on the integrity of the acromioclavicular ligaments and capsule as well as the coracoclavicular ligaments and the trapezius and deltoid muscles. Along with clinical examination for tenderness and instability, radiographic examination is critical in the evaluation of acromioclavicular joint injuries. Nonsurgical treatment is indicated for type I and II injuries; surgery is almost always recommended for type IV, V, and VI injuries. Management of type III injuries remains controversial, with nonsurgical treatment favored in most instances and reconstruction of the acromioclavicular joint reserved for symptomatic instability. Recommended techniques for stabilization in cases of acute and late symptomatic instability include screw fixation of the coracoid process to the clavicle, coracoacromial ligament transfer, and coracoclavicular ligament reconstruction. Biomechanical studies have demonstrated that anatomic acromioclavicular joint reconstruction is the most effective treatment for persistent instability.

Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases: a prospective comparative study

BACKGROUND

Biomechanical studies comparing various surgical techniques for acromioclavicular joint reconstruction have reported that semitendinosus tendon graft for coracoclavicular ligament reconstruction provides a substantial improvement in initial stability and a load-to-failure equivalent to the intact coracoclavicular ligaments. Although it represents a biomechanical improvement compared with coracoacromial ligament transfer, there is still a lack of prospective comparative studies confirming the clinical relevance of these biomechanical findings.

HYPOTHESIS

Semitendinosus tendon graft for coracoclavicular ligament reconstruction is associated with superior clinical results compared with a modified Weaver-Dunn procedure in chronic complete acromioclavicular joint dislocation.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Twenty-four patients (mean age, 42 years) with painful, chronic Rockwood type III through V acromioclavicular joint dislocations were subjected to surgical reconstruction. In 12 patients, a modified Weaver-Dunn procedure was performed; in the other 12 patients, autogenous semitendinosus tendon graft was used. Clinical evaluation was performed using the American Shoulder and Elbow Surgeons shoulder score and the Constant score after a mean follow-up time of 37 months. Preoperative and postoperative radiographs were compared.

RESULTS

The mean American Shoulder and Elbow Surgeons shoulder score improved from 74 +/- 7 points preoperatively to 86 +/- 8 points postoperatively in the Weaver-Dunn group, and from 74 +/- 4 points to 96 +/- 5 points in the semitendinosus tendon group (P < .001 for both techniques). The mean Constant score improved from 70 +/- 8 points to 81 +/- 8 points in the Weaver-Dunn group, and from 71 +/- 5 points to 93 +/- 7 points in the semitendinosus tendon group (P < .001). The results in the semitendinosus tendon group were significantly better than in the Weaver-Dunn group (P < .001). The radiologic measurements showed a mean coracoclavicular distance of 12.3 +/- 4 mm in the Weaver-Dunn group increasing to 14.9 +/- 6 mm under stress loading, compared with 11.4 +/- 3 mm increasing to 11.8 +/- 3 mm under stress in the semitendinosus tendon group. The difference during stress loading was statistically significant (P = .027). In the semitendinosus tendon group, horizontal displacement of the lateral clavicle end could be reduced in all cases with type IV dislocation.

CONCLUSION

Semitendinosus tendon graft for coracoclavicular ligament reconstruction resulted in significantly superior clinical and radiologic outcomes compared to the modified Weaver-Dunn procedure.

Arthroscopically assisted coracoclavicular ligament reconstruction for chronic acromioclavicular joint instability

The treatment of symptomatic chronic acromioclavicular joint dislocations can be challenging. Different surgical procedures have been described in the literature. We present an arthroscopically assisted stabilization using a gracilis tendon transclavicular-transcoracoid loop technique augmented with a Tight-Rope (Arthrex, Naples, FL, USA). In contrast to the classic Weaver-Dunn procedures this technique is designed to stabilize the acromioclavicular joint by recreating the anatomy of the coracoclavicular ligaments via a minimal invasive approach.

Cyclical loading of coracoclavicular ligament reconstructions: a comparative biomechanical study

BACKGROUND

Reconstruction for injuries to the acromioclavicular joint remains controversial.

HYPOTHESIS

A coracoclavicular ligament reconstruction with a semitendinosus tendon would have superior performance to the classic coracoacromial ligament transfer with or without augmentation.

STUDY DESIGN

Controlled laboratory study.

METHODS

Five cadaveric shoulders were used to reconstruct the coracoclavicular ligaments with 3 methods: coracoacromial ligament transfer without augmentation, coracoacromial ligament transfer augmented with No. 5 Ethibond suture, and a semitendinosus tendon. Each reconstruction was cyclically loaded at 40 N to 80 N for 2500 cycles, then from 40 N to 210 N for 2500 cycles, followed by loading to failure. The number of cycles to 50% and 100% loss of acromioclavicular joint reduction were recorded.

RESULTS

During the 40 N to 80 N-loading cycle, the coracoacromial transfer without augmentation failed (15 +/- 16 cycles). The augmented coracoacromial ligament transfer and the semitendinosus reconstruction did not fail (P = .008). During the 40 N to 210 N-loading cycle, the augmented coracoacromial ligament transfer failed (207 +/- 399 cycles). The semitendinosus reconstruction survived through both loading cycles (P < .01).

CONCLUSION

Coracoclavicular ligament reconstruction with a semitendinosus graft is a biomechanically superior construct in a cyclically loaded setting to a coracoacromial ligament transfer augmented with a No. 5 Ethibond suture.

CLINICAL RELEVANCE

The semitendinosus graft is a strong, biologic option for reconstruction of the coracoclavicular ligaments.

Acromioclavicular and sternoclavicular joint injuries

Acromioclavicular (AC) joint injuries are a frequent diagnosis following an acute shoulder injury. The literature on AC joint dislocation is extensive, reflecting the intense debate surrounding the topic. The choice of treatment is influenced by factors including the type of injury, the patient's occupation, the patient's past medical history, the acuity of the injury, and patient expectations. Sternoclavicular (SC) joint dislocation is an uncommon injury. The treatment of acute anterior SC joint dislocations is controversial. It is difficult to study with a well-designed prospective study because of the low frequency of this injury. Posterior dislocations are much less common than anterior dislocations. Posterior dislocations, however, are more serious; they are associated with significant complications and require prompt attention.