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Li Y, Cai J, Li P, Pang L, Li J, Tang X. Suture Button Could Result in More Functional Outcomes Improvement and Pain Relief Than Hook Plate Technique for Treating Acute Acromioclavicular Joint Dislocation: A Systematic Review of Comparative Studies. Arthroscopy 2024; 40:553-566. [PMID: 37315745 DOI: 10.1016/j.arthro.2023.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 05/12/2023] [Accepted: 05/18/2023] [Indexed: 06/16/2023]
Abstract
PURPOSE To systematically review the current evidence to compare the differences in outcomes of the suture button (SB) versus hook plate (HP) fixations for treating acute acromioclavicular joint dislocation (ACD). METHODS Two independent reviewers performed the literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of the Embase, PubMed, and Cochrane Library databases was performed and Level I-IV evidence studies comparing the SB and HP procedures for acute ACD were included. Studies that met the following exclusion criteria were excluded: (1) letters, comments, case reports, reviews, animal studies, cadaveric studies, biomechanical studies, and study protocols; (2) incomplete data; and (3) repeated studies and data. The Newcastle-Ottawa Scale was used to evaluate the quality of nonrandomized studies. Constant score, visual analog scale (VAS) score, operation time, coracoclavicular distance (CCD), and complications were recorded and the mean differences of VAS and Constant were compared with preset minimal clinically important difference. RESULTS Fourteen studies with 363 patients treated with SB procedures and 432 patients with the HP procedure were included. In terms of patient-reported outcomes, 5 of the 13 included studies reported significantly greater Constant score in SB group and most (4/5) used arthroscopic SB technique. Statistically significant differences in favor of SB were found in 3 of the 7 included studies in terms of VAS score whereas none of them reached the minimal clinically important difference. In terms of recurrent instability, no statistically significant difference was noted. All studies showed that the SB technique resulted in lower estimated blood loss. No difference was detected in CCD and complications. CONCLUSIONS Based on the current body of evidence, it is suggested that employment of the SB technique may confer advantageous outcomes when compared to the HP technique in acute ACD patients. These potential benefits may include higher Constant scores, lower pain levels, and no discernible increases in operation time, CCD, or complication rates. LEVEL OF EVIDENCE Level IV, systematic review of Level II-IV studies.
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Affiliation(s)
- Yinghao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Jie Cai
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Pengcheng Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China; West China School of Nursing, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Long Pang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Jian Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
| | - Xin Tang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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Rashid MS, Lo IK. Editorial Commentary: Acute Treatment Including Cerclage Result in Best Surgical Outcomes for High-Grade Acromioclavicular Joint Separations. Arthroscopy 2023; 39:2291-2292. [PMID: 37866871 DOI: 10.1016/j.arthro.2023.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 10/24/2023]
Abstract
Despite years of research, optimal treatment of acute high-grade acromioclavicular joint (ACJ) separations remains controversial. ACJ separations occur in a "multiplanar" fashion and identification of horizonal plane instability is paramount to differentiate between high-grade versus low-grade injuries. As surgeons, we treat a self-selected group of patients referred for surgery, and our physiotherapy colleagues may rehabilitate many patients with both "low-grade" and "high-grade" separations who compensate. Of importance, ACJ separations stabilized <3 weeks after injury have the best chance of healing in a close-to anatomic position. The addition of the ACJ cerclage augmentation improves horizontal plane stability while the soft tissues heal and likely improves outcome.
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Berthold DP, Muench LN, Dyrna F, Mazzocca AD, Garvin P, Voss A, Scheiderer B, Siebenlist S, Imhoff AB, Beitzel K. Current concepts in acromioclavicular joint (AC) instability - a proposed treatment algorithm for acute and chronic AC-joint surgery. BMC Musculoskelet Disord 2022; 23:1078. [PMID: 36494652 PMCID: PMC9733089 DOI: 10.1186/s12891-022-05935-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 10/30/2022] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Daniel P. Berthold
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany ,grid.411095.80000 0004 0477 2585Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Lukas N. Muench
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Felix Dyrna
- Department of Trauma, Hand and Reconstructive Surgery University Hospital Münster, Munich, Germany
| | - Augustus D. Mazzocca
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 USA
| | - Patrick Garvin
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 USA
| | - Andreas Voss
- grid.7727.50000 0001 2190 5763Department of Trauma Surgery, University Regensburg, Regensburg, Germany
| | - Bastian Scheiderer
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Sebastian Siebenlist
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Andreas B. Imhoff
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Knut Beitzel
- Arthroscopy and Orthopedic Sportsmedicine, ATOS Orthoparc Clinic, Cologne, Germany
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Scheiderer B, Obmann S, Feucht MJ, Siebenlist S, Degenhardt H, Imhoff AB, Rupp MC, Pogorzelski J. The Morphology of the Acromioclavicular Joint Does Not Influence the Postoperative Outcome Following Acute Stabilization—A Case Series of 81 Patients. Arthrosc Sports Med Rehabil 2022; 4:e835-e842. [PMID: 35747655 PMCID: PMC9210376 DOI: 10.1016/j.asmr.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 09/07/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose To specifically evaluate the influence of the acromioclavicular (AC)-joint morphology on the outcome after arthroscopically assisted coracoclavicular (CC) stabilization surgery with suspensory fixation systems and to investigate whether an additional open AC-joint reduction and AC cerclage improves the clinical outcome for patients with certain morphologic AC-joint subtypes. Methods Patients with an acute acromioclavicular joint injury, who underwent arthroscopically assisted CC stabilization with suspensory fixation systems with or without concomitant AC cerclage between January 2009 and June 2017 were identified and included in this retrospective cohort analysis. AC-joint morphology was assessed on preoperative radiographs and categorized as “flat” or “non-flat” (“oblique”/“curved”) subtypes. After a minimum of 2 years of follow-up, postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES), and visual analog scale (VAS) scores for pain were collected. A subgroup analysis of clinical outcomes depending on the surgical technique and morphological subtype of the AC joint was performed. Results Eighty-one patients (95% male, mean age 35 ± 12 years) could be included at a mean follow-up of 57 ± 14 months. Radiographic assessment of AC-joint morphology showed 24 (30%) cases of flat type, 38 (47%) cases of curved type, and 19 (23%) cases of oblique morphology. Postoperatively, no clinically significant difference could be detected after the treatment of AC joint injury via CC stabilization with or without concomitant AC cerclage (VASrest: P = .067; VASmax: P = .144, ASES: P = .548; SANE: P = .045). No clinically significant differences were found between the surgical techniques for the flat morphologic subtype (VASrest: P = .820; VASmax: P = .251; SANE: P = .104; ASES: P = .343) or the non-flat subtype (VASres: P = .021; VASmax: P = .488; SANE: P = .243, ASES: P = .843). Conclusions In arthroscopically assisted AC stabilization surgery with suspensory fixation systems for acute AC-joint injury, the AC-joint morphology did not influence the postoperative outcome, independent of the surgical technique. No clinical benefit of performing an additional horizontal stabilization could be detected in our collective at mid-term follow-up. Level of Evidence Level IV, therapeutic case series.
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Velasquez Garcia A, Salamé Castillo F, Ekdahl Giordani M, Mura Mardones J. Anteroinferior bundle of the acromioclavicular ligament plays a substantial role in the joint function during shoulder elevation and horizontal adduction: a finite element model. J Orthop Surg Res 2022; 17:73. [PMID: 35123523 PMCID: PMC8818233 DOI: 10.1186/s13018-022-02966-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative acromioclavicular (AC) ligament deficiency has been identified as a common cause of failure after isolated coracoclavicular reconstruction. The two-bundle arrangement of the acromioclavicular ligament has recently been reported in histological and anatomical research. In addition, a clear structural advantage of the superoposterior bundle (SPB) over the less consistent anteroinferior bundle (AIB) was also found. However, the current understanding of the function of the acromioclavicular ligament in joint stability is based on uniaxial bone loading experiments and sequential ligament sectioning. Consequently, these rigid biomechanics models do not reproduce the coupled physiological kinematics, neither in the normal joint nor in the postoperative condition. Therefore, our goal was to build a quasi-static finite element model to study the function of the acromioclavicular ligament based on its biomechanical performance patterns using the benefits of computational models. Methods A three-dimensional bone model is reconstructed using images from a healthy shoulder. The ligament structures were modeled according to the architecture and dimensions of the bone. The kinematics conditions for the shoulder girdle were determined after the osseous axes aligned to simulate the shoulder elevation in the coronal plane and horizontal adduction. Three patterns evaluated ligament function. The peak von Mises stress values were recorded using a clock model that identified the stress distribution. In addition, the variation in length and displacement of the ligament during shoulder motion were compared using a two-tailed hypotheses test. P values < 0.01 were considered statistically significant. Results The peak von Mises stress was consistently observed in the AIB at 2:30 in coronal elevation (4.06 MPa) and horizontal adduction (2.32 MPa). Except in the position 2:00, statistically significant higher deformations were identified in the two bundles during shoulder elevation. The highest ligament displacement was observed on the Y- and Z-axes. Conclusions The AIB has the primary role in restricting the acromioclavicular joint during shoulder motion, even though the two bundles of the AC ligament have a complementary mode of action. During horizontal adduction, the SPB appears to prevent anterior and superior translation. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-02966-0.
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Bockmann B, Venjakob AJ, Thrasyvoulidis G, Holschen M, Schulte TL, Nebelung W. Sonographic Measurement of Dynamic Horizontal Instability in Acromioclavicular Joint Instability: Description of a Simple Technique and Correlation to Radiographic Parameters. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:409-415. [PMID: 33955022 DOI: 10.1002/jum.15719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 04/05/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Dynamic horizontal instability is considered to be the main reason for poor outcome after treatment for acromioclavicular (AC) joint instability. In this study, we describe a simple technique to quantify this pathology via sonography. METHODS Thirty-six shoulders from 18 patients with ac joint instabilities were examined using modified Alexander views and a standardized sonographic examination. On the Alexander views, overlap of acromion and clavicle (OLAC), glenoid center to posterior clavicle distance (GCPC), and lateral extension (LE) were measured. Afterwards, the results were analyzed and compared with sonography. Posterior translation of the clavicle and the difference of translation between healthy and injured shoulder were evaluated. RESULTS The mean age of the patients was 39 ± 14 years (range 19-61 years). We included 4 (22%) Rockwood type 3, 1 (6%) Rockwood type 4, and 13 (72%) Rockwood type 5 lesions. Four (22%) patients were female and 14 (78%) male patients. Posterior clavicle translation of the injured shoulder correlated strongly between OLAC and sonography (r = -0.514, P = .029), and the difference of translation between healthy and injured shoulder correlated very strongly between LE and sonography (r = 0.737, P < .001). CONCLUSION The sonographic measurement technique for horizontal instability presented in this work could help detect horizontal instabilities. While the observation of dynamic horizontal displacement is a strength of this technique, measurements are hindered in cases of high coracoclavicular distances. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
- Benjamin Bockmann
- Department of Orthopaedics and Trauma Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
- Department of Sports Orthopaedics, St. Vinzenz Hospital, Düsseldorf, Germany
| | | | | | - Malte Holschen
- Orthopedic Practice Clinic (OPPK) and Raphaelsklinik Münster, Münster, Germany
| | - Tobias Ludger Schulte
- Department of Orthopaedics and Trauma Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Wolfgang Nebelung
- Department of Sports Orthopaedics, St. Vinzenz Hospital, Düsseldorf, Germany
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Ligamentous healing potential of the acromioclavicular ligament following acute anatomical reconstruction. Arch Orthop Trauma Surg 2022; 142:2225-2234. [PMID: 34013381 PMCID: PMC9381440 DOI: 10.1007/s00402-021-03936-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/02/2021] [Indexed: 10/27/2022]
Abstract
BACKGROUND Horizontal instability following acute acromioclavicular joint (ACJ) reconstruction still occurs with a high prevalence. Although the human acromioclavicular ligament complex (ACLC) represents the major horizontal ACJ stabilizer, experimental studies on healing characteristics are lacking. Therefore, the purpose of this histological study was to investigate the healing potential of the ACLC following acute anatomical reconstruction METHODS: In this prospective clinical-experimental study, 28 ACLC biopsies were performed in patients with complete ACJ dislocations (Rockwood type 4 or 5) during acute hook plate stabilization (IG: implantation group; n = 14) and hook plate removal (EG: explantation group; n = 14). Histological analyses included Giemsa staining, polarized light microscopy and immunostaining against CD68, αSMA and collagen type I and type III. Histomorphological evaluation entailed cell counts, collagen expression score, ligament tissue maturity index (LTMI) and descriptive analysis of specific ligamentous structures. Statistics consisted of nonparametric Mann-Whitney U tests and a level of significance of P < .05. RESULTS Total cell counts (cells/mm2 1491 ± 296 vs. 635 ± 430; P < 0.001) and collagen III expression (3.22 ± 0.22 vs. 1.78 ± 0.41; P < 0.001) were higher in EG compared to IG. Inversely αSMA + (11 ± 9 vs. 179 ± 186; P < 0.001) and CD68 + cell counts (56 ± 20 vs. 100 ± 57; P 0.009) were significantly lower in the EG. The EG revealed a comparable reorientation of ligamentous structures. Consistently, ACLC samples of the EG (21.6 ± 2.4) displayed a high total but differently composed LTMI score (IG: 24.5 ± 1.2; P < 0.001). CONCLUSIONS This experimental study proved the ligamentous healing potential of the human ACLC following acute anatomical reconstruction. Histomorphologically, the ACLC reliably showed a ligamentous state of healing at a mean of about 12 weeks after surgery. However, processes of ligamentous remodeling were still evident. These experimental findings support recent clinical data showing superior horizontal ACJ stability with additional AC stabilization in the context of acute ACJ reconstruction. Though, prospective clinical and biomechanical studies are warranted to evaluate influencing factors on ACLC healing and potential impacts of acute ACLC repair on clinical outcome. STUDY TYPE Controlled Laboratory Study.
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DiCosmo MB, Rumpf N, Mancini MR, Obopilwe E, Arciero RA, Mazzocca AD. Clavicular-Sided Tears Were the Most Frequent Mode of Failure During Biomechanical Analysis of Acromioclavicular Ligament Complex Failure During Adduction of the Scapula. Arthrosc Sports Med Rehabil 2021; 3:e1723-e1728. [PMID: 34977626 PMCID: PMC8689223 DOI: 10.1016/j.asmr.2021.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 07/30/2021] [Indexed: 11/25/2022] Open
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Mowbray JL, Moreno G, Albers CG, Poon P. The reverse coracoacromial ligament transfer for "horizontal" acromioclavicular joint instability. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:381-388. [PMID: 37588719 PMCID: PMC10426700 DOI: 10.1016/j.xrrt.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Acromioclavicular (AC) horizontal instability is a problem affecting not only young athletic patients after a trauma to the AC joint but also older patients who have undergone distal clavicle resection. It may cause pain and poor functional outcomes unless the reconstruction technique specifically addresses the horizontal instability of the clavicle, in addition to the well-known superior instability. Methods Three cadaveric specimens underwent dissection of the AC joint capsule to determine the superior attachments of the AC joint capsule. These shoulders subsequently underwent distal clavicle resection and were loaded to a 7-kg weight in the horizontal plane. The horizontal displacement of the clavicle was measured and resection continued to the point of horizontal instability of the clavicle. Thereafter, the reverse coracoacromial ligament reconstruction technique was performed and recreation of horizontal stability assessed. Utilization of the reverse coracoacromial ligament transfer in two clinical cases will also be presented. Results The AC joint capsule is continuous with trapezius and deltoid insertions. The average distance between the articular surface and insertion of the capsule on the clavicle is 10 mm and on the acromion is 14.8 mm. Horizontal clavicular translation increased from 2.3 mm when intact to 3.3 mm with capsular transection, 8.7 mm with 5 mm clavicle resection, and finally 15 mm with a 10-mm clavicle resection. Horizontal instability of the clavicle was demonstrated with a 10-mm clavicle resection. Conclusion Horizontal instability of the clavicle is evident with distal clavicle resection of greater than 10 mm. A reverse coracoacromial ligament transfer may be a reasonable technique to address horizontal stability of the clavicle during AC joint reconstruction in the context of painful instability.
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Affiliation(s)
- Jessica L. Mowbray
- Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
| | - Gabriela Moreno
- Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
| | | | - Peter Poon
- Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
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Lee J, El-Daou H, Alkoheji M, Carlos A, Di Mascio L, Amis A. Ligamentous and capsular restraints to anterior-posterior and superior-inferior laxity of the acromioclavicular joint: a biomechanical study. J Shoulder Elbow Surg 2021; 30:1251-1256. [PMID: 33010434 DOI: 10.1016/j.jse.2020.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Approximately 9% of shoulder girdle injuries involve the acromioclavicular joint (ACJ). There is no clear gold standard or consensus on surgical management of these injuries, in part perpetuated by our incomplete understanding of native ACJ biomechanics. We have therefore conducted a biomechanical study to assess the stabilizing structures of the ACJ in superior-inferior (SI) translation and anterior-posterior (AP) translation. METHODS Twenty fresh frozen cadaveric specimens were prepared and mounted onto a robotic arm. The intact native joint was tested in SI translation and AP translation under a 50-N displacing force. Each specimen was retested after sectioning of its stabilizing structures in the following order: investing fascia, ACJ capsular ligaments, trapezoid ligament, and conoid ligament. Their contributions to resisting ACJ displacements were calculated. RESULTS In the intact native ACJ, mean anterior displacement of the clavicle was 7.9 ± 4.3 mm, mean posterior displacement was 7.2 ± 2.6 mm, mean superior displacement was 5.8 ± 3.0 mm, and mean inferior displacement was 3.6 ± 2.6 mm. The conoid ligament was the primary stabilizer of superior displacement (45.6%). The ACJ capsular ligament was the primary stabilizer of inferior displacement (33.8%). The capsular ligament and conoid ligament contributed equally to anterior stability, with rates of 23% and 25.2%, respectively. The capsular ligament was the primary contributor to posterior stability (38.4%). CONCLUSION The conoid ligament is the primary stabilizer of superior displacement of the clavicle at the ACJ and contributes significantly to AP stability. Consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries.
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Affiliation(s)
- Jillian Lee
- Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK.
| | - Hadi El-Daou
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Mohamed Alkoheji
- Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Adrian Carlos
- Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Livio Di Mascio
- Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Andrew Amis
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
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Teixeira Ramos J, Silva Gomes D, Quinaz Neto P, Sarmento M, Moura N, Cartucho A. Arthroscopic-Assisted Acromioclavicular Joint Dislocation Repair: A Modified Technique for Horizontal Stabilization Using Suture Anchors. Arthrosc Tech 2021; 10:e283-e288. [PMID: 33680757 PMCID: PMC7917010 DOI: 10.1016/j.eats.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023] Open
Abstract
Acromioclavicular (AC) dislocation is a common lesion often resulting from a sports injury. Nowadays, treatment is still controversial mainly in grade III lesions according to the Rockwood classification. For most surgically treated AC acute dislocations, treatment is performed with an arthroscopic procedure that anatomically reconstructs the coracoclavicular ligaments. Increasing knowledge about AC joint biomechanics has underlined the importance of its horizontal stability through the superior and inferior AC ligaments. Moreover, the pattern of lesion tends to repeat itself, with the superior AC ligament being torn most frequently from the clavicular side in a peeling fashion. Therefore, the purpose of this note is to describe the technical aspects of additional horizontal stability through superior AC ligament repair using suture anchors.
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Affiliation(s)
- Jorge Teixeira Ramos
- Department of Orthopedic Surgery, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal,Address correspondence to Jorge Teixeira Ramos, M.D., Department of Orthopedic Surgery, Hospital Vila Franca de Xira, Estrada Carlos Lima Costa No. 2, 2600-009 Vila Franca de Xira, Portugal.
| | - Diogo Silva Gomes
- Department of Orthopedic Surgery, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal,Shoulder and Elbow Unit, Department of Orthopedic Surgery, Hospital CUF Descobertas, Lisbon, Portugal,Department of Orthopedic Surgery, Hospital Particular do Algarve, Algarve, Portugal
| | - Pedro Quinaz Neto
- Department of Orthopedic Surgery, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
| | - Marco Sarmento
- Shoulder and Elbow Unit, Department of Orthopedic Surgery, Hospital CUF Descobertas, Lisbon, Portugal
| | - Nuno Moura
- Shoulder and Elbow Unit, Department of Orthopedic Surgery, Hospital CUF Descobertas, Lisbon, Portugal
| | - António Cartucho
- Shoulder and Elbow Unit, Department of Orthopedic Surgery, Hospital CUF Descobertas, Lisbon, Portugal
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Acromioclavicular joint reconstruction implants have differing ability to restore horizontal and vertical plane stability. Knee Surg Sports Traumatol Arthrosc 2021; 29:3902-3909. [PMID: 34436636 PMCID: PMC8595167 DOI: 10.1007/s00167-021-06700-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/11/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE Persistent acromioclavicular joint (ACJ) instability following high grade injuries causes significant symptoms. The importance of horizontal plane stability is increasingly recognised. There is little evidence of the ability of current implant methods to restore native ACJ stability in the vertical and horizontal planes. The purpose of this work was to measure the ability of three implant reconstructions to restore native ACJ stability. METHODS Three groups of nine fresh-frozen shoulders each were mounted into a robotic testing system. The scapula was stationary and the robot displaced the clavicle to measure native anterior, posterior, superior and inferior (A, P, S, I) stability at 50 N force. The ACJ capsule, conoid and trapezoid ligaments were transected and the ACJ was reconstructed using one of three commercially available systems. Two systems (tape loop + screw and tape loop + button) wrapped a tape around the clavicle and coracoid, the third system (sutures + buttons) passed directly through tunnels in the clavicle and coracoid. The stabilities were remeasured. The data for A, P, S, I stability and ranges of A-P and S-I stability were analyzed by ANOVA and repeated-measures Student t tests with Bonferroni correction, to contrast each reconstruction stability versus the native ACJ data for that set of nine specimens, and examined contrasts among the reconstructions. RESULTS All three reconstructions restored the range of A-P stability to that of the native ACJ. However, the coracoid loop devices shifted the clavicle anteriorly. For S-I stability, only the sutures + buttons reconstruction did not differ significantly from native ligament restraint. CONCLUSIONS Only the sutures + buttons reconstruction, that passed directly through tunnels in the clavicle and coracoid, restored all stability measures (A, P, S, I) to the native values, while the tape implants wrapped around the bones anteriorised the clavicle. These findings show differing abilities among reconstructions to restore native stability in horizontal and vertical planes. (300 words).
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White LM, Ehmann J, Bleakney RR, Griffin AM, Theodoropoulos J. Acromioclavicular Joint Injuries in Professional Ice Hockey Players: Epidemiologic and MRI Findings and Association With Return to Play. Orthop J Sports Med 2020; 8:2325967120964474. [PMID: 33283007 PMCID: PMC7686611 DOI: 10.1177/2325967120964474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/12/2020] [Indexed: 01/12/2023] Open
Abstract
Background: Acromioclavicular joint (ACJ) injuries are common in ice hockey players and
are traditionally evaluated with conventional radiography, which has
recognized limitations in the accurate characterization of the spectrum of
soft tissue injuries and severity/grade of injury sustained. Purpose: To evaluate the epidemiologic, clinical, and magnetic resonance imaging (MRI)
findings in professional ice hockey players who have sustained acute ACJ
injuries. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was performed of professional National Hockey League
(NHL) players referred for MRI evaluation of acute ACJ injuries. All MRI
scans were assessed for status of the ACJ, ligamentous stabilizers, and
surrounding musculature. MRI-based overall grade of ACJ injury (modified
Rockwood grade 1-6) was assigned to each case. Data regarding mechanism of
injury, player handedness, clinical features, and return to play were
evaluated. Results: Overall, 24 MRI examinations of acute ACJ injuries (23 patients; mean age, 24
years) were reviewed. We found that 50% of injuries were sustained during
the first period of play, and in 75% of cases, injuries involved the same
side as player shooting handedness. Analysis of MRI scans revealed 29%
(7/24) grade 1 ACJ injuries, 46% (11/24) grade 2 injuries, 21% (5/24) grade
3 injuries, and 4% (1/24) grade 5 injuries. Trapezius muscle strains were
seen in 79% and deltoid muscle strain in 50% of cases. Nonoperative
management was used for 23 injuries; 1 patient (grade 5 injury) underwent
acute reconstructive surgery. All players successfully returned to
professional NHL competition. Excluding cases with additional injuries or
surgery (n = 3) or convalescence extending into the offseason (n = 3), we
found that the mean return to play was 21.4 days (7.2 games missed). No
statistically significant difference was observed in return to play between
nonoperatively treated grade 3 injuries (mean, 28.3 days) and grade 1 or 2
injuries (mean, 20.1 days). However, grade 3 injuries were associated with a
greater number of NHL scheduled games missed (mean, 12.7) compared with
lower grade injuries (mean, 6.1) (P = .027). Conclusion: The spectrum of pathology and grading of acute ACJ injuries sustained in
professional ice hockey can be accurately assessed with MRI; the majority of
injuries observed in this study were low grade (grades 1 and 2). Although
grade 3 injuries were associated with a greater number of games missed,
similar return-to-play results were observed between nonoperatively treated
grade 3 and grade 1 or 2 ACJ injuries.
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Affiliation(s)
- Lawrence M White
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.,Joint Department of Medical Imaging, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jonathan Ehmann
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.,Joint Department of Medical Imaging, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Robert R Bleakney
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.,Joint Department of Medical Imaging, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anthony M Griffin
- Department of Orthopedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - John Theodoropoulos
- Department of Orthopedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada.,Orthopedic Sports Medicine, University of Toronto, Toronto, Ontario, Canada
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The acromioclavicular ligament shows an early and dynamic healing response following acute traumatic rupture. BMC Musculoskelet Disord 2020; 21:593. [PMID: 32887599 PMCID: PMC7487736 DOI: 10.1186/s12891-020-03614-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose Symptomatic horizontal instability is clinically relevant following acute acromioclavicular joint dislocations. However, the intrinsic healing response is poorly understood. The present study sought to investigate time-dependent healing responses of the human acromioclavicular ligament following acute traumatic rupture. Methods Biopsies of the acromioclavicular ligament were obtained from patients undergoing surgical treatment for acute acromioclavicular joint dislocations. Specimens were stratified by time between trauma and surgery: group 1, 0–7 days (n = 5); group 2, 8–14 days (n = 6); and group 3, 15–21 days (n = 4). Time-dependent changes in cellularity, collagen (type 1 and 3) concentration, and histomorphological appearance were evaluated for the rupture and intact zone of the acromioclavicular ligament. Results Group 1 was characterized by cellular activation and early inflammatory response. The rupture zone exhibited a significantly higher count of CD68-positive cells than the intact zone (15.2 vs 7.4; P ≤ 0.05). Consistently, synovialization of the rupture end was observed. Within the second week, the rupture zone was subject to proliferation showing more fibroblast-like cells than the intact zone (66.8 vs 43.8; P ≤ 0.05) and a peak of collagen type 3 expression (group 1: 2.2 ± 0.38, group 2: 3.2 ± 0.18, group 3: 2.8 ± 0.57; P ≤ 0.05). Signs of consolidation and early remodeling were seen in the third week. Conclusions The acromioclavicular ligament exhibits early and dynamic healing responses following acute traumatic rupture. Our histological findings suggest that surgical treatment of acute ACJ dislocations should be performed as early as possible within a timeframe of 1 week after trauma to exploit the utmost biological healing potential. Prospective clinical studies are warranted to investigate whether early surgical treatment of ACJ dislocations translates into clinical benefits.
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Flores DV, Goes PK, Gómez CM, Umpire DF, Pathria MN. Imaging of the Acromioclavicular Joint: Anatomy, Function, Pathologic Features, and Treatment. Radiographics 2020; 40:1355-1382. [PMID: 32762593 DOI: 10.1148/rg.2020200039] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The acromioclavicular joint is an important component of the shoulder girdle; it links the axial skeleton with the upper limb. This joint, a planar diarthrodial articulation between the clavicle and the acromion, contains a meniscus-like fibrous disk that is prone to degeneration. The acromioclavicular capsule and ligaments stabilize the joint in the horizontal direction, while the coracoclavicular ligament complex provides vertical stability. Dynamic stability is afforded by the deltoid and trapezius muscles during clavicular and scapular motion. The acromioclavicular joint is susceptible to a broad spectrum of pathologic entities, traumatic and degenerative disorders being the most common. Acromioclavicular joint injury typically affects young adult males and can be categorized by using the Rockwood classification system as one of six types on the basis of the direction and degree of osseous displacement seen on conventional radiographs. MRI enables the radiologist to more accurately assess the regional soft-tissue structures in the setting of high-grade acromioclavicular separation, helping to guide the surgeon's selection of the appropriate management. Involvement of the acromioclavicular joint and its stabilizing ligaments is also important for understanding and classifying distal clavicle fractures. Other pathologic processes encountered at this joint include degenerative disorders; overuse syndromes; and, less commonly, inflammatory arthritides, infection, metabolic disorders, and developmental malformations. Treatment options for acromioclavicular dysfunction include conservative measures, resection arthroplasty for recalcitrant symptoms, and surgical reconstruction techniques for stabilization after major trauma.
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Affiliation(s)
- Dyan V Flores
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Paola Kuenzer Goes
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Catalina Mejía Gómez
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Darwin Fernández Umpire
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Mini N Pathria
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
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Morikawa D, Huleatt JB, Muench LN, Kia C, Berthold DP, Cote MP, Obopilwe E, Kelolli D, Scheiderer B, Mazzocca AD. Posterior Rotational and Translational Stability in Acromioclavicular Ligament Complex Reconstruction: A Comparative Biomechanical Analysis in Cadaveric Specimens. Am J Sports Med 2020; 48:2525-2533. [PMID: 32692952 DOI: 10.1177/0363546520939882] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Persistent posterior instability of the acromioclavicular (AC) joint is a reported complication after isolated coracoclavicular (CC) reconstruction. Thus, multiple techniques have been proposed attempting to restore biomechanics of the AC ligament complex (ACLC). PURPOSE/HYPOTHESIS The purpose was to evaluate the posterior translational and rotational stability of an ACLC reconstruction with a dermal allograft (ACLC patch) as compared with 3 suture brace constructs. It was hypothesized that the ACLC patch would better restore AC joint posterior stability. STUDY DESIGN Controlled laboratory study. METHODS A total of 28 cadaveric shoulders (mean ± SD age, 57.6 ± 8.3 years) were randomly assigned to 1 of 4 surgical techniques: ACLC patch, oblique brace, anterior brace, and x-frame brace. The force and torque to achieve 10 mm of posterior translation and 20° of posterior rotation of the AC joint were recorded in the following conditions: intact, transected ACLC, ACLC patch/brace repair, ACLC patch/brace repair with dissected CC ligaments, and ACLC patch/brace repair with CC ligament repair. RESULTS For posterior translation, transection of the ACLC reduced resistance to 16.7% of the native. With the native CC ligaments intact, the ACLC patch (59.1%), oblique brace (54.1%), and anterior brace (60.7%) provided significantly greater stability than the x-frame brace (33.2%; P < .001, P = .008, P < .001, respectively). ACLC patch, oblique brace, and anterior brace continued to have significantly higher posterior translational resistance than the x-frame (35.1%; P < .001, P = .003, P < .001) after transection and subsequent CC ligament repair. For posterior rotation, transection of the ACLC decreased the resistance to 5.4% of the intact state. With the CC ligaments intact, the ACLC patch (77.1%) better restored posterior rotational stability than the oblique (35.3%), anterior (48.5%), and x-frame (23.0%) brace repairs (P < .001, P = .002, P < .001). CC ligament transection and subsequent repair demonstrated the ACLC patch (41.0%) to have improved stability when compared with the oblique (16.0%), anterior (14.0%), and x-frame (12.7%) repairs (P = .006, P = .003, P = .002). CONCLUSION ACLC reconstruction with a dermal allograft better restored native posterior rotational stability than other brace constructs, with translational stability similar to the oblique and anterior brace technique at the time of surgery. CLINICAL RELEVANCE Horizontal stability of the AC joint is primarily controlled by the ACLC. Inability to restore AC joint biomechanics can result in persistent posterior instability and lead to functional impairment.
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Affiliation(s)
- Daichi Morikawa
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Surgery, Juntendo University, Tokyo, Japan
| | - Joel B Huleatt
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Lukas N Muench
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Cameron Kia
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Daniel P Berthold
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Denis Kelolli
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA.,Department of Civil, Environmental, and Biomedical Engineering, College of Engineering and Technology and Architecture, University of Hartford, West Hartford, Connecticut, USA
| | - Bastian Scheiderer
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
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Aliberti GM, Kraeutler MJ, Trojan JD, Mulcahey MK. Horizontal Instability of the Acromioclavicular Joint: A Systematic Review. Am J Sports Med 2020; 48:504-510. [PMID: 31013137 DOI: 10.1177/0363546519831013] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injuries to the acromioclavicular (AC) joint are common and should be suspected in patients who have shoulder pain in the region of the acromion and clavicle. Injuries to the AC ligament can cause horizontal instability and are often neglected or underdiagnosed, which can lead to poor patient outcomes. PURPOSE To perform a systematic review of the literature on the diagnosis and treatment of horizontal instability of the AC joint. STUDY DESIGN Systematic review. METHODS The authors performed a systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies that investigated diagnosis, treatment, and failure of operative management of acute and chronic AC separations. Studies that did not specifically evaluate AC joint injuries, were not written in English, or were specific only to vertical instability of the AC joint were excluded. RESULTS Overall, 23 articles met the inclusion criteria and were therefore included in this systematic review. Diagnosing horizontal AC instability is difficult using plain radiographs; dynamic views were shown in some cases to better detect horizontal instability than with static views. More than 60 procedures for treating AC joint injuries have been published, but many focus on vertical rather than horizontal instability. Modifications to current surgical procedures to incorporate reconstruction of the horizontal component showed improved patient outcomes. Such modifications included additional AC joint suture cord cerclage, combined AC and coracoclavicular ligament reconstruction, and the Twin Tail TightRope triple button technique. Failure after surgical stabilization of AC joint separation has been reported to occur in 15% to 80% of cases. CONCLUSION No consensus is available regarding the best practices for diagnosis, evaluation, and treatment of acute or chronic horizontal instability of the AC joint. Moreover, horizontal instability injuries are often neglected or poorly understood, making diagnosis difficult, which may lead to high complication rates and failure after surgical stabilization.
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Affiliation(s)
| | - Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey, USA
| | - Jeffrey D Trojan
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Morikawa D, Mazzocca AD, Obopilwe E, Cote MP, Kia C, Johnson JD, Imhoff FB, Scheiderer B. Reconstruction of the Acromioclavicular Ligament Complex Using Dermal Allograft: A Biomechanical Analysis. Arthroscopy 2020; 36:108-115. [PMID: 31864562 DOI: 10.1016/j.arthro.2019.07.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 07/12/2019] [Accepted: 07/14/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the posterior translational and rotational stability of the acromioclavicular (AC) joint following reconstruction of the superior acromioclavicular ligament complex (ACLC) using dermal allograft. METHODS Six fresh-frozen cadaveric shoulders were used (mean age of 65.3 ± 6.9 years). The resistance force against posterior translation (10 mm) and torque against posterior rotation (20°) was measured. Specimens were first tested with both the intact ACLC and coracoclavicular ligaments. The ACLC and coracoclavicular ligaments were then transected so simulate a Type III/V AC joint dislocation. Each specimen then underwent 3 testing conditions, performed in the following order: (1) ACLC patch reconstruction alone, (2) ACLC patch with an anatomic coracoclavicular reconstruction (ACCR) using semitendinosus allograft, and (3) the transected ACLC with an ACCR only. Differences in posterior translational and rotational torque across testing conditions were analyzed with a one-way repeated analysis of variance analysis. RESULTS Mean resistance against posterior translation in the intact condition was 65.76 ± 23.8 N. No significant difference found between the intact condition compared with specimens with the ACLC-patch only (44.2 ± 11.3 N, P = .06). The ACCR technique, when tested alone, had significantly less posterior translational resistance compared with the intact condition (38.5 ± 8.94 N, P = .008). ACLC patch in combination with an ACCR was closest in restoring native posterior translation (57.1 ± 19.2 N, P = .75). For rotational resistance, only the addition of the ACLC patch with an ACCR (0.51 ± 0.07 N-m) demonstrated similar torque compared with the intact joint (0.89 ± 0.5 N-m, P = .06). CONCLUSIONS The ACLC-patch plus ACCR technique was able to closest restore the percent of normal posterior translational and rotational stability. CLINICAL RELEVANCE Recurrent posterior instability of the AC joint is a potential complication after coracoclavicular reconstruction surgery. In the in vitro setting, this study demonstrated increased AC joint stability with the addition of an ACLC reconstruction using dermal allograft.
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Affiliation(s)
- Daichi Morikawa
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A.; Department of Orthopaedic Surgery, Juntendo University, Tokyo, Japan.
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Cameron Kia
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Jeremiah D Johnson
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Florian B Imhoff
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A.; Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Bastian Scheiderer
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A.; Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
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Martetschläger F, Kraus N, Scheibel M, Streich J, Venjakob A, Maier D. The Diagnosis and Treatment of Acute Dislocation of the Acromioclavicular Joint. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:89-95. [PMID: 30892184 DOI: 10.3238/arztebl.2019.0089] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/09/2018] [Accepted: 11/22/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The acromioclavicular joint (ACJ) is one of the more common sites of shoulder girdle injury, accounting for 4-12% of all such injuries, with an incidence of 3-4 cases per 100 000 persons per year in the general population. Current topics of debate include the proper standard diagnostic evaluation, the indications for surgery, and the best operative method. METHODS This review is based on publications retrieved by a selective literature search. RESULTS Mechanical trauma of the ACG can tear the ligamentous apparatus that holds the acromion, clavicle, and coracoid process together. Different interventions are indicated depending on the nature of the injury. In recent years, the horizontal component of the instability has received more attention, in addition to its vertical component. Persistent instability can lead to chronic, painful limitation of shoulder function, particularly with respect to working above the head. Surgical stabilization is therefore recommended for high-grade instability of Rockwood types IV and V. Modern reconstruction techniques enable selective vertical and horizontal treatment of the instability and have been found superior to traditional methods, particularly in young athletes. Arthroscopic techniques are advantageous because they are less invasive, do not require removal of implanted material, and afford the opportunity to diagnose any accompanying lesions definitively and to treat them if necessary. Surgery for acute injuries should be performed within three weeks of the trauma. For chronic injuries, additional tendon augmentation is now considered standard treatment. CONCLUSION High-grade ACJ instability is a complex and significant injury of the shoulder girdle that can cause persistent pain and functional impairment. The state of the evidence regarding its optimal treatment is weak. Large-scale, prospective, randomized comparative studies are needed in order to define a clear standard of treatment.
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Affiliation(s)
- Frank Martetschläger
- German Center of Shoulder Surgery, ATOS Clinic Munich, Department of Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany; Upper Extremity Department, Schulthess Clinic Zurich; Center for Musculoskeletal Surgery (CMSC), Charité-University Medicine Berlin, Berlin, Germany; Department of Orthopedic Surgery, Alfried Krupp Hospital Essen, Essen, Germany; Department of Sports Orthopedics, Marienkrankenhaus Kaiserswerth, Düsseldorf, Germany; Department of Orthopedics and Trauma Surgery, University Hospital Freiburg, Freiburg, Germany; The authors are members of the Shoulder Committee of the German Society of Arthroscopy and Joint Surgery (AGA, Deutsche Gesellschaft für Arthroskopie und Gelenkchirurgie)
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Bedeutung und Behandlung der horizontalen Instabilitätskomponente bei Verletzungen des Akromioklavikulargelenks. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s11678-019-0525-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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