Return-to-activity after anatomical reconstruction of acute high-grade acromioclavicular separation

3D C-arm navigated suture button implantation for AC joint dislocations - the pilot study

PURPOSE

The surgical treatment of acute traumatic AC joint dislocations is still a subject of scientific debate in the literature. The arthroscopically assisted stabilization procedure with a suture button system has been successfully established and is widely used in daily practice. It is minimally invasive and allows the anatomical reconstruction of the torn coracoclavicular ligaments in one step with a permanent implant that does not have to be removed in a second operation. This clinical pilot study is the first to describe the new method of navigated suture button implantation with the future aim of further reducing surgical invasiveness and further increasing surgical precision.

MATERIALS AND METHODS

10 patients with a Rockwood 3b/5 injury could be included in the prospective study (DRKS00031855) within 5 months according to inclusion and exclusion criteria. Surgical stabilization was performed with a suture button system via a navigated coracoclavicular drill tunnel. Demographic and radiological data as well as information on health and shoulder function were collected from patient records, X-rays, DVT scan and 3 questionnaires (DASH, NHS and Eq. 5D) at the preoperative, intraoperative and postoperative (discharge, 6 weeks and 3 months) time points.

RESULTS

All operations could be performed within 8.8 days (± 6.81) after trauma. The average operation time was 50.3 min (± 8.81). The mean distance of the drill hole in the clavicle to the AC joint was 26.6 mm (± 2.63). The radiologically measured vertical coracoclavicular distance was 38.8 mm (± 6.16) at discharge and 41.11 mm (± 7.51) at 3 months. This loss of reduction was not statistically significant. In contrast, the DASH, NHS and Eq. 5D results showed significant improvement from discharge to 3 months postoperatively.

CONCLUSION

Image-guided 3D C-arm navigated AC joint suture button stabilization is feasible in everyday surgical practice. It may be possible to achieve a further reduction in invasiveness while at the same time increasing the accuracy of implant positioning. Further clinical studies with a larger number of patients and a longer follow-up period are necessary to enable a comparison with conventional methods.

Return to Play After Surgical Treatment for Acromioclavicular Joint Dislocation: A Systematic Review

BACKGROUND

Acromioclavicular (AC) joint dislocation is a common clinical problem among young and athletic populations. Surgical management is widely used for high-grade dislocations (Rockwood III-VI) and in high-demand athletes at high risk of recurrence.

PURPOSE

To systematically review the evidence in the literature to ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after surgical treatment for AC joint dislocation.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted in the PubMed database. Clinical studies were eligible for inclusion if they reported on RTP after surgical treatment for AC joint dislocation. Statistical analysis was performed with SPSS.

RESULTS

We found 120 studies including 4327 cases meeting our inclusion criteria. The majority of patients were male (80.2%), with a mean age of 37.2 years (range, 15-85) and a mean follow-up of 34.5 months. Most were recreational athletes (79%), and the most common sport was cycling. The overall rate of RTP was 91.5%, with 85.6% returning to the same level of play. Among collision athletes, the rate of RTP was 97.3%, with 97.2% returning to the same level of play. In overhead athletes, the rate of RTP was 97.1%, with 79.2% returning to the same level of play. The mean time to RTP was 5.7 months (range, 1.5-15). Specific RTP criteria were reported in the majority of the studies (83.3%); time to return to play was the most commonly reported item (83.3%). Type III Rockwood injuries had the highest RTP rate at 98.7% and the earliest RTP at 4.9 months. Among the different surgical techniques, Kirschner wire fixation had the highest rate of RTP at 98.5%, while isolated graft reconstruction had the earliest RTP at 3.6 months.

CONCLUSION

The overall rate of RTP was reportedly high after surgical treatment for AC joint dislocation, with the majority of patients returning to their preinjury levels of sport. There is a lack of consensus in the literature for what constitutes a safe RTP, with further focus on this topic required in future studies.

Long-Term Functional Outcomes and Athletic Ability in Shoulder Sports After Anatomic Coracoclavicular Ligament Reconstruction for Chronic Type 3 and 5 Acromioclavicular Joint Injuries

Background

Promising short- and midterm outcomes have been seen after anatomic coracoclavicular ligament reconstruction (ACCR) for chronic acromioclavicular joint (ACJ) injuries.

Purpose/Hypothesis

To evaluate long-term outcomes and shoulder-related athletic ability in patients after ACCR for chronic type 3 and 5 ACJ injuries. It was hypothesized that these patients would maintain significant functional improvement and sufficient shoulder-sport ability at a long-term follow-up.

Study Design

Case series; Level of evidence, 4.

Methods

Included were 19 patients (mean age, 45.9 ± 11.2 years) who underwent ACCR for type 3 or 5 ACJ injuries between January 2003 and August 2014. Functional outcome measures included the American Shoulder and Elbow Surgeons (ASES), Rowe, Constant-Murley, Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores as well as the visual analog scale (VAS) for pain, which were collected preoperatively and at the final follow-up. Postoperative shoulder-dependent athletic ability was assessed using the Athletic Shoulder Outcome Scoring System (ASOSS). Shoulder activity level was evaluated using the Shoulder Activity Scale (SAS), while the Subjective Patient Outcome for Return to Sports (SPORTS) score was collected to assess the patients' ability to return to their preinjury sporting activity.

Results

The mean follow-up time was 10.1 ± 3.8 years (range, 6.1-18.8 years). Patients achieved significant pre- to postoperative improvements on the ASES (from 54.2 ± 22.6 to 83.5 ± 23.1), Rowe (from 66.6 ± 18.1 to 85.3 ± 19), Constant-Murley (from 64.6 ± 20.9 to 80.2 ± 22.7), SST (from 7.2 ± 3.4 to 10.5 ± 2.7), SANE (from 30.1 ± 23.2 to 83.6 ± 26.3), and VAS pain scores (from 4.7 ± 2.7 to 1.8 ± 2.8) (P < .001 for all), with no significant differences between type 3 and 5 injuries. At the final follow-up, patients achieved an ASOSS of 80.6 ± 32, SAS level of 11.6 ± 5.1, and SPORTS score of 7.3 ± 4.1, with no significant differences between type 3 and 5 injuries. Four patients (21.1%) had postoperative complications.

Conclusion

Patients undergoing ACCR using free tendon allografts for chronic type 3 and 5 ACJ injuries maintained significant improvements in functional outcomes at the long-term follow-up and achieved favorable postoperative shoulder-sport ability, activity, and return to preinjury sports participation.

Mini-open vs. arthroscopic double tight-rope reconstruction after acute AC-joint dislocation: a comparison in functional outcome and sports activity

INTRODUCTION

In athletes, acromioclavicular joint disruptions account for up to 50% of all shoulder injuries. In high-grade injuries, surgery is favored to ensure a correct restoration of the joint, especially in young athletes. The aim of this study was to compare the clinical, radiological and sport related outcomes of the arthroscopic stabilization with the fixation of the AC joint in a mini-open approach.

MATERIALS AND METHODS

19 patients treated arthroscopically (ASK) and 26 patients with an acute AC-joint dislocation Rockwood V who had undergone the mini-open (MO) surgery were included. Constant Murley Score (CMS), Taft Score (TS) and the Simple Shoulder Tests (SST) were evaluated. The sports activity level was determined according to Valderrabano and the athlete's recovery of their athletic activity level after surgery according to Rhee. Furthermore, all available X-ray images were analyzed.

RESULTS

Patients in the ASK group achieved an average score of 11.7 ± 0.6 points in the SST, 10.3 ± 1.8 points in the TS and 91.2 ± 11.8 points in the CMS. On average, patients in the MO group achieved results of 10.5 ± 1.4 points in the SST, 11.7 ± 0.7 points in the TS and 91.6 ± 9.8 points in the CMS. The ASK group showed significant difference regarding the CC distance in side comparison (Δ = 3.6 mm), whereas no significant difference was found in the MO group (Δ = 0.8 mm). In comparison of both groups, the posterior as well as the combined translation were significantly greater in the ASK group than in the MO group (posterior: ASK: 24.8 mm, MO: 19.3 mm, combined: ASK: 29.1 mm, MO: 20.9 mm). Residual horizontal instability was greater in the ASK group (43%) than in the MO group (32%). Similar results were achieved in sports activity and the recovery of athletic activity (Valderrabano: ASK: 2.8, MO: 2.6; Rhee: ASK: 1.6, MO: 1.5).

CONCLUSIONS

Both techniques prove to be effective for the stabilization of high-grade AC-joint disruptions in athletes and showed excellent clinical results. From a radiographic standpoint, the mini-open procedure appears superior to the arthroscopic technique. After mini-open surgery postoperative loss of correction is less common and greater horizontal stability is achieved. The results also suggest the mini-open technique is superior to the arthroscopic procedure when aiming to restore the athlete's original level of sports activity.

LEVEL OF EVIDENCE: 1

[Minimally Invasive Techniques for the Treatment of Acute and Chronic Acromioclavicular Joint Instabilities]

Acromioclavicular joint instabilities are one of the most common injuries of the shoulder girdle. Diagnostic measures include the vertical and horizontal components of instability. The main goals of treatment include pain reduction, joint stabilization, and return to physical activity. For operative treatment, there are numerous techniques available. Recently, minimally-invasive techniques were developed and showed equal results as with open approach. These procedures facilitate simultaneous treatment of concomitant shoulder lesions and reduce soft tissue trauma as well as the risk of infection. This article presents an overview of such minimally-invasive techniques for both acute and chronic instabilities. Both techniques address the aspect of horizontal instability, which was found to compromise clinical results. For an acute injury, we describe the use of a low-profile button system combined with an additional acromioclavicular cerclage. In the chronic setting with a bidirectional (vertical and horizontal) instability, a free tendon graft combined with a single TightRope augmentation is recommended.

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

Background

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

Methods

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

Results

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

Conclusion

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

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.

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up

PURPOSE

To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.

METHODS

A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated.

RESULTS

There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated.

CONCLUSIONS

AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction.

LEVEL OF EVIDENCE

IV (Case Series).

[Arthroscopically-assisted treatment of acute and chronic dislocations of the acromioclavicular joint : A prospective clinical trial]

BACKGROUND

Injuries of the acromioclavicular joint (ACJ) are frequent and often occur during sports. While arthroscopically-assisted stabilization of acute injuries of the ACJ is a well-established procedure, there is not much data available for arthroscopically-assisted stabilization of chronic injuries of the ACJ.

OBJECTIVES

This study assesses clinical and radiological results of arthroscopically-assisted stabilization of acute and chronic injuries of the ACJ.

MATERIALS AND METHODS

Thirty-six patients with acute and chronic injuries of the ACJ were assessed in a prospective clinical trial. Twenty-five patients with acute injuries (group A) and eleven patients with chronic injuries (group B) were included in this study. Patients of group A were operated using two suture-button systems, while patients of group B received one suture-button system and an autologous gracilis tendon graft.

RESULTS

In group A, the mean preoperative Constant score rated 38, and the ASES score rated 34. At follow-up the Constant score (92) and the ASES score (89) had improved. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (15.8 mm) in comparison to the contralateral shoulder (10.9 mm). In group B, the preoperative Constant score measured 57. It improved to 72 points at follow-up. The ASES score improved from 39 to 72 points in the same period. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (18.9 mm) in comparison to the contralateral shoulder (12.4 mm).

CONCLUSIONS

Stabilization of acute injuries of the ACJ with two suture-button systems is related to very good shoulder function after one year. The native coracoclavicular distance cannot be restored with this procedure. Stabilization of chronic injuries of the ACJ with a suture-button system and an autologous gracilis tendon graft is related to improved shoulder function after one year. However, shoulder function cannot be fully restored with the stabilization technique presented.

Coracoclavicular Space Widening on Radiographs After Arthroscopic Stabilization With Suspensory Fixation Does Not Affect Athletic Performance

Purpose

To evaluate the effect of the coracoclavicular distance widening in athletes after arthroscopic acromioclavicular (AC) stabilization using a suspensory button fixation device in terms of function, athletic performance, or isokinetic assessment.

Methods

Sixty-eight athletes with a minimum 6-month follow-up after AC stabilization using suspensory button fixation were allocated in 2 groups, the widening group and non-widening group, according to the measured coracoclavicular distance after 6 months from the operation. The assessment was done every 6 months by Subjective Patient Outcome for Return to Sports (SPORTS) score, Athletic Shoulder Outcome Scoring System (ASOSS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, Constant-Murley score (CMS), and the coracoclavicular distance. Isokinetic testing was performed at 24 months postoperatively to evaluate shoulder abduction and external rotation strength.

Results

No statistically significant differences were found between the 2 groups in terms of the DASH, ASOSS, SPORTS, and the CMS, in addition to the isokinetic testing (P > .05). A statistically significant improvement in both groups over the follow-up stage was identified in the DASH, ASOSS, SPORTS, and the CMS (P < .05).

Conclusions

Coracoclavicular distance widening following arthroscopic suspensory button fixation for AC joint dislocation did not affect function, athletic performance, or isokinetic evaluation in athletes.

Level of Evidence

III; nonrandomized, comparative trial.

Editorial Commentary: Early Surgery and Restricted Rehabilitation Are Recommended for High-Grade Acromioclavicular Joint Dislocation

Despite acromioclavicular (AC) joint injuries being common, there are still controversies about the treatment; nonoperative versus surgical, who to operate, when to operate, which technique to use, and which rehabilitation protocol to use. Orthopaedic surgeons are often faced with these patients fearing not regaining normal function and to some degree acceptable cosmetic outcomes. Despite increasing interest in surgical management of type 3 AC joint injuries, surgical management has not been demonstrated to yield superior functional outcomes compared with nonoperative treatment. Interestingly, studies have demonstrated that good outcomes are achieved with most surgical techniques even though they are all associated with loss of initial reduction. This brings into question whether surgery is necessary in the early phase and how we can mitigate the effects of gravity to maintain reduction. Studies that can aid surgeons in patient selection for treatment protocols (nonoperative versus surgical) and timing of surgery are needed. We recommend early surgery, and restricted rehabilitation, for high-grade acromioclavicular joint dislocation.

Glenohumeral Migration of Intraosseous Suture- Button after Acromioclavicular JointACJ Reconstruction - A Case Report

INTRODUCTION

Acromioclavicular joint (ACJ) separation is a common sports injury. Suture- button repair is favoured technique with a complication rate of 20%. We are the first to report the migration of a suture button into the glenohumeral joint.

CASE REPORT

A 28-year-old right-handed rugby player presented with symptoms of laxity and catching within the right shoulder 4 years after reconstruction using an ACJ Dog Bone TM Technique (Arthrex Inc.). Magnetic resonance imaging showed that the coracoid suture button had migrated into the glenohumeral joint.

CONCLUSION

The patient was successfully treated with an arthroscopic examination of the glenohumeral joint and removal of the button. We outline the risk factors and treatment options involved in this unique presentation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSION

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

Acromioclavicular joint injuries in overhead athletes: a concise review of injury mechanisms, treatment options, and outcomes

PURPOSE OF THE REVIEW

To review the relevant literature surrounding acromioclavicular (AC) joint injuries particularly pertaining to overhead athletes.

RECENT FINDINGS

The AC joint is a unique anatomic and biomechanical portion of the shoulder that can be problematic for athletes, particularly throwers, when injured. Treatment of these injuries remains a topic in evolution. Low-grade injuries (Rockwood types I & II) are typically treated non-operatively while high-grade injuries (types IV, V, and VI) are considered unstable and often require operative intervention. Type III AC separations remain the most controversial and challenging as no clear treatment algorithm has been established. A wide variety of surgical techniques exist. Unfortunately, relatively little literature exists with regard to overhead athletes specifically. Treatment of AC joint injuries remains challenging, at times, particularly for overhead athletes. Operative indications and techniques are still evolving, and more research is needed specifically surrounding overhead athletes.

Return to sport after surgical treatment for high-grade (Rockwood III-VI) acromioclavicular dislocation

PURPOSE

Acromioclavicular (AC) joint dislocations are common in a young and active population, especially in people performing contact sports. Full recovery with a fast and high rate of return to sport is desirable. This systematic review aims to combine patient outcomes in order to help surgeons in addressing patient expectations regarding the return to sport after surgical intervention for AC dislocations.

METHODS

To conduct this systematic review, the PRISMA guidelines were followed. Articles were included if written in English or Dutch and evaluated return to sport after any type of surgical intervention for Rockwood types III to VI AC dislocations in patients practicing sports. Outcome parameters were return to sport, time to return to sport, level of sport, functional outcome scores and complications.

RESULTS

Twelve studies involving 498 patients were included, of which 462 patients practiced sports. 432 (94%) patients returned to sport. The weighted mean time to return to sport was 4.0 months. 338 out of 401 patients (84%) returned to the same level of pre-injury sport and 35 patients (9%) lowered their level of sport. The weighted mean Constant score was 92 out of 100.

CONCLUSION

The rate of return to sport after surgical intervention for Rockwood (RW) III-VI AC dislocations is high. However, the level of evidence was low and due to the methodological heterogeneity between studies, subgroup analyses of return to sport outcomes were not feasible.

LEVEL OF EVIDENCE

Systematic review of level I-IV studies, level IV.

Return to sport after acute acromioclavicular stabilization: a randomized control of double-suture-button system versus clavicular hook plate compared to uninjured shoulder sport athletes

PURPOSE

Traumatic high-grade acromioclavicular joint (ACJ) separations can be surgically stabilized by numerous anatomic and non-anatomic procedures. The return to sport (Maffe et al. in Am J Sports Med 23:93-98, 1995] and remaining sport-associated impairments after acute ACJ stabilization has not yet been investigated.

METHODS

73 consecutive athletes with acute high-grade ACJ separation were prospectively assigned into two groups (64.4% randomized, 35.6% intention-to-treat): open clavicular hook plate (cHP) implantation (GI) or arthroscopically assisted double double-suture-button (dDSB) implantation (GII). Patients were analyzed using shoulder sport-specific measurement tools for sport ability (ASOSS), sport activity (SSAS), and numerical analog scales: NAS_{pain during sport}, NAS_{shoulder function in sport}, and NAS_{re-achievement of sport level}. Four points of examination were established: preoperative evaluation (FU0) and first postoperative follow-up (FU1) at 6 months; FU2 at 12 months; and FU3 at 24 months after surgery. The control group (GIII) consisted of 140 healthy athletes without anamnesis of prior macro-injury or surgery.

RESULTS

After surgical stabilization, 29 of 35 athletes in GI (82.9%; 38.6 ± 9.9 years) and 32 of 38 in GII (82.9%; 38.6 ± 9.9 years) were followed up for 24 months (FU3) (loss 17.8%). All operated athletes showed significantly increased scores compared to FU0 (p < 0.05). Compared to GI, GII showed significantly superior outcome data for sporting ability as well as for NAS_{re-achievement of sport level} (p < 0.05). While GII re-achieved GIII-comparable SSAS and ASOSS levels, GI remained at a significantly inferior level. Athletes after ACJ injury of Rockwood grade IV/V and overhead athletes benefited significantly from the dDSB procedure.

CONCLUSION

The dDSB procedure enabled significantly superior sport-specific outcomes compared to the cHP procedure. Athletes after dDSB surgeries re-achieved the sporting ability and the sport activity levels of healthy athletes, whereas athletes after cHP implantation remained at significantly inferior levels. The more extensive dDSB procedure and the more restrictive rehabilitation are recommended for treatment of acute high-grade ACJ separations of functionally high-demanding athletes.

LEVEL OF EVIDENCE

I.

Return to Sport and Clinical Outcomes After Surgical Management of Acromioclavicular Joint Dislocation: A Systematic Review

PURPOSE

To evaluate the rate at which athletes return to sport after surgical management of acute and chronic acromioclavicular (AC) joint dislocations.

METHODS

Three databases-PubMed, MEDLINE, and EMBASE-were searched from database inception until October 28, 2017, by 2 reviewers independently and in duplicate. The inclusion criteria were English language studies that reported return to sport outcomes in patients undergoing surgical management of AC joint dislocations.

RESULTS

Overall, 12 studies with a combined total of 315 patients met the inclusion criteria, with a mean age of 33.8 years (range, 18-65 years) and a mean follow-up of 34.9 months (range, 6-126 months). Of the 12 included studies, 1 was a prospective comparative study (Level II), 1 was a retrospective comparative study (Level III), 1 was a prospective case series (Level IV), and 9 were retrospective case series (Level IV). The rates of return to any level of sport ranged from 94% to 100% (I² = 0%), whereas the rates of return to the preinjury level of sport ranged from 62% to 100% (I² = 61%). The pooled rate of return to preinjury level of sport in type V AC joint separations was 86.2% (95% confidence interval = 68.1%-98.0%), whereas that after type III or IV AC joint injuries was 89.6% (95% confidence interval = 79.9%-96.9%).

CONCLUSIONS

An almost perfect rate of return to sport participation after surgical management of AC joint dislocations have been reported, with most returning to their preinjury level of sport. The rates of return to sport were comparable across the different types of injuries and surgical procedures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV investigations.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Injury patterns of the acromioclavicular ligament complex in acute acromioclavicular joint dislocations: a cross-sectional, fundamental study

BACKGROUND

Horizontal instability impairs clinical outcome following acute acromioclavicular joint (ACJ) reconstruction and may be caused by insufficient healing of the superior acromioclavicular ligament complex (ACLC). However, characteristics of acute ACLC injuries are poorly understood so far. Purposes of this study were to identify different ACLC tear types, assess type-specific prevalence and determine influencing cofactors.

METHODS

This prospective, cross-sectional study comprised 65 patients with acute-traumatic Rockwood-5 (n = 57) and Rockwood-4 (n = 8) injuries treated operatively by means of mini-open ACJ reduction and hook plate stabilization. Mean age at surgery was 38.2 years (range, 19-57 years). Standardized pre- and intraoperative evaluation included assessment of ACLC tear patterns and cofactors related to the articular disc, the deltoid-trapezoidal (DT) fascia and bony ACJ morphology. Articular disc size was quantified as 0 = absent, 1 = remnant, 2 = meniscoid and 3 = complete.

RESULTS

All patients showed complete ruptures of the superior ACLC, which could be assigned to four different tear patterns. Clavicular-sided (AC-1) tears were observed in 46/65 (70.8 %), oblique (AC-2) tears in 12/65 (18.5 %), midportion (AC-3) tears in 3/65 (4.6 %) and acromial-sided (AC-4) tears in 4/65 (6.1 %) of cases. Articular disc size manifestation was significantly (P < .001) more pronounced in patients with AC-1 tears (1.89 ± 0.57) compared to patients with AC-2 tears (0.67 ± 0.89). Other cofactors did not influence ACLC tear patterns. ACLC dislocation with incarceration caused mechanical impediment to anatomical ACJ reduction in 14/65 (21.5 %) of cases including all Rockwood-4 dislocations. Avulsion "in continuity" was a consistent mode of failure of the DT fascia. Type-specific operative strategies enabled anatomical ACLC repair of all observed tear types.

CONCLUSIONS

Acute ACLC injuries follow distinct tear patterns. There exist clavicular-sided (AC-1), oblique (AC-2), midportion (AC-3) and acromial-sided (AC-4) tears. Articular disc size was a determinant factor of ACLC tear morphology. Mini-open surgery was required in Rockwood-4 and a relevant proportion of Rockwood-5 dislocations to achieve both anatomical ACLC and ACJ reduction. Type-specific operative repair of acute ACLC tears might promote biological healing and lower rates of horizontal ACJ instability following acute ACJ reconstruction.