Is coracoclavicular reconstruction necessary in hook plate fixation for acute unstable acromioclavicular dislocation?

Subacromial osteolysis following hook plate fixation for acromioclavicular dislocation: a systematic review and meta-analysis

BACKGROUND

Clavicular hook plates are extensively used in the treatment of acromioclavicular dislocation. Subacromial osteolysis is a typical complication following hook plate fixation. We performed a systematic review and meta-analysis to determine the incidence of subacromial osteolysis and analyzed the associated characteristics of subacromial osteolysis to guide surgeons.

METHODS

PubMed, EMBASE, and Cochrane Library databases were comprehensively searched for relevant literature. We screened the literature based on the eligibility criteria, extracted relevant data, and assessed the quality of the included studies. Pooled odds ratios or mean differences with 95% confidence intervals (CIs) were calculated by a fixed-effects or random-effects model. Heterogeneity was evaluated by the chi-squared test and I2 statistics. A meta-regression analysis was performed to explore the potential source of heterogeneity.

RESULTS

Thirty-two studies met the inclusion criteria. The total pooled incidence of subacromial osteolysis was 29% and the only covariate that could influence the incidence of subacromial osteolysis was the radiological measurement method (P = .017). Patients in the hook plate fixation with coracoclavicular ligament reconstruction group had lower odds of subacromial osteolysis (odds ratio, 2.54, 95% CI 1.54-4.18; P < .001). There were no significant differences in the Constant-Murley scores at the final follow-up between patients with and without subacromial osteolysis (standardized mean difference, -0.17; 95% CI, -0.50 to 0.15; P = .294).

CONCLUSIONS

Subacromial osteolysis has a relatively high and variable incidence, and the primary factor influencing the reported incidence is the radiological assessment method. The current analysis suggests coracoclavicular ligament reconstruction as an effective surgical approach for decreasing the incidence of subacromial osteolysis. The presence or absence of subacromial osteolysis did not significantly impact the functional outcomes observed during the final follow-up period.

Comparison of Effectiveness and Safety in Treating Acute Acromioclavicular Joint Dislocation with Five Different Surgical Procedures: A Systematic Review and Network Meta-Analysis

This network meta-analysis aims to evaluate the comparative effectiveness and safety of suture anchors (SA), tendon grafts (TG), hook plates (HP), Tight-Rope (TR), and EndoButton (EB) in the treatment of acute acromioclavicular joint (ACJ) dislocation. The Embase, PubMed, and Web of Science databases were searched from their inception date to June 3, 2022. Studies included all eligible randomized controlled trials (RCTs) and cohort studies with the comparison of five different fixation systems among SA, TG, HP, TR, and EB were identified. All studies were reviewed, performed data extraction, and assessed the risk of bias independently by two reviewers. The primary outcomes are Constant-Murley score (CMS) improvement for assessing clinical efficacy, and complications. The second outcomes are visual analog scale (VAS) for assessing pain relief and the coracoclavicular distance (CCD) for assessing postoperative joint reduction. Version 2 of the revised Cochrane risk of bias tool for randomized trials (RoB 2) and the risk of bias in nonrandomized studies of interventions (ROBINS-I) were used to assess the RCTs and non-randomized trials, respectively. The continuous outcomes were presented as mean differences (MD), and risk ratios (OR) were used for dichotomous outcomes, both with 95% confidence intervals (CI). Surface under the cumulative ranking curves (SUCRA) results were calculated to offer a ranking of each intervention. We identified 31 eligible trials, including 1687 patients in total. HP showed less CMS improvement than TR and EB in both the Network Meta-analysis (NMA) and pairwise meta-analysis. HP also showed less CMS improvement than SA in NMA. For pain relief, HP performed worse than TR both in pairwise meta-analysis and NMA. No significant differences were found for the measured value of CCD. Both TR and EB showed a lower incidence of complications than HP in pairwise meta-analysis. The rank of SUCRA for CMS improvement was as follows: SA, TR, EB, TG, and HP; for pain relief: TR, EB, TG, SA, and HP; for CCD: HP, TR, SA, EB, and TG. For complications, HP showed the highest rank, followed by TG, EB, TR, and SA. SA shows better clinical effectiveness and reliable safety in the treatment of acute ACJ dislocation. Although HP is the most widely used surgical option currently, it should be carefully taken into consideration for its high incidence of complications.

SURGICAL TREATMENT OF ACROMIOCLAVICULAR DISLOCATION: HOOK PLATE VERSUS SUTURE BUTTON

Objectives

We aimed to compare the functional and radiographical outcomes of reconstruction of acute unstable acromioclavicular joint (ACJ) dislocation using Hook Plate (HP) versus Suture Endobutton (SE) fixation techniques.

Methods

Forty-six consecutive patients with grade III to V ACJ dislocation according to Rockwood classification who underwent either HP or SE fixation in the period between January 2017 and June 2020 were evaluated. The treatment modalities were divided into either HP or SE fixation. The radiological assessment included standard anterior-posterior (AP) views to evaluate coracoclavicular (CC) distances for vertical reduction.

Results

CC distances were grouped as preoperative (CC¹), early postoperative (CC²), and late postoperative (CC³). The distance variance between CC² and CC³ was referred as ΔCC (CC³ - CC²). A statistically significant difference was found in ΔCC between the two groups (p=0.008). ΔCC was significantly higher in the SE group compared to the HP group (p<0.05). The Constant and UCLA Scores of patients in the SE group were found to be significantly higher than in the HP group patients.

Conclusion

Clinical outcomes were more satisfactory in patients with acute unstable ACJ dislocation who underwent SE compared to HP procedures, at the end of the first year. Evidence Level IV; Case Series.

Clavicular hook plate for acute high-grade acromioclavicular dislocation involving Rockwood type V: clinical and radiological outcomes and complications evaluation

Background

The surgical treatment of high-grade acromioclavicular joint dislocation remains a matter of debate. Clavicular hook plate internal fixation was widely used in the treatment of acromioclavicular dislocation because of its easy-to-master surgical technique. This study aimed to evaluate outcomes using hook plate fixation for acromioclavicular dislocation.

Methods

A consecutive series of 57 patients with acute acromioclavicular joint dislocation involving Rockwood type V were treated between November 2013 and September 2019 using hook plate fixation. The functional outcomes (using the visual analogue score, Constant-Murley score, and University of California Los Angeles score), the quality of surgical reduction (using the coracoclavicular distance), and post-operative complications were assessed with about 46 months of follow-up.

Results

The mean Constant-Murley score increased from 72.6 before surgery to 87.6 at final follow-up. The mean University of California Los Angeles score was 14.1 pre-operatively and 31.6 at final follow-up. Meanwhile, the visual analogue scores were significantly reduced from 3.4 pre-operatively to 1.3 post-operatively. The coracoclavicular distance decreased from 19.4 mm pre-operatively to 10.9 mm at the last follow-up. Post-operative functional and radiological outcomes were significantly improved compared with pre-operative outcomes (P < 0.01). The overall excellent and good result was 35.1% (20/57) and 54.1% (31/57), respectively. At follow-up, the overall complication rate was 15.8% (9/57) including subacromial impingement (three patients), acromial osteolysis (three patients), reduction loss (one patient), acromioclavicular joint osteoarthritis (one patient), and calcification (one patient).

Conclusion

Hook plate fixation was a viable treatment approach, and achieved good clinical outcomes in the treatment of acute acromioclavicular dislocation involving V. But some complications of hook plate fixation should not be ignored.

Hook plate fixation with versus without coracoclavicular reconstruction for distal clavicular fractures

PURPOSE

Hook plate fixation is one of the most frequently used methods for unstable distal clavicular fractures, but it is still unknown if there is a need for coracoclavicular (CC) reconstruction. This study aimed to compare the efficacy of hook plate fixation with versus without CC reconstruction for distal clavicular fractures.

METHODS

Eighty-one patients who underwent hook plate fixation (HP group, n = 45) or hook plate fixation plus suture anchor reconstruction (HPA group, n = 36) for Neer type II or V clavicular fractures were enrolled. Demographics, fracture characteristics, and surgical data were recorded. Union time, coracoclavicular distance (CCD), post-operative complications, Constant score, and Disabilities of the Arm, Shoulder, and Hand (DASH) score were compared between HPA and HP groups.

RESULTS

Constant score in the HPA group was higher than that in the HP group (91.8 ± 3.6 vs 88.8 ± 6.0, P = 0.007). However, there were no significant differences in union time, DASH score, CCD, and post-operative complications between the two groups (P > 0.05). Hook plate fixation combined with CC reconstruction costed more (3023.7 ± 202.6 vs 2416.2 ± 167.6 EUR, P < 0.001) and prolonged operative duration (78.2 ± 9.2 vs 73.7 ± 8.3 min, P = 0.023) compared with hook plate fixation alone.

CONCLUSION

Hook plate fixation with or without suture anchor reconstruction achieved satisfactory outcomes for Neer type II or V clavicular fractures. However, hook plate fixation plus CC reconstruction showed better functional outcomes compared with hook plate fixation alone.

Does coracoclavicular augmentation additional to hook plate fixation provide benefits in acute unstable acromioclavicular dislocation? A meta-analysis

Background

Acromioclavicular joint (ACJ) dislocation is a common shoulder injury. In treating acute unstable ACJ dislocation, a hook plate (HP) is a straightforward and popular option for ensuring proper reduction and rigid fixation while promoting AC and coracoclavicular (CC) ligament healing. Surgeons typically remove the HP to prevent subacromial impingement and acromial osteolysis; however, concerns about redislocation after implant removal remain. Therefore, additional CC augmentation may be helpful in combination with HP fixation. The aim of this meta-analysis is to compare the outcomes and complications of HP fixation with or without additional CC augmentation for acute unstable ACJ dislocation.

Methods

We searched the PubMed, EMBASE, and Web of Science databases for relevant case–control studies. The primary outcomes were patient-reported outcome measures; the secondary outcomes were pain measured using a visual analog scale (VAS), CC distance (CCD), and complications. Continuous data were assessed using weighted standardized mean differences (SMDs) with 95% confidence intervals (CIs), and dichotomous data were evaluated with Mantel–Haenszel odds ratio (ORs) with 95% CIs.

Results

We analyzed one randomized control trial and four case–control studies comparing HP fixation with or without CC augmentation. A total of 474 patients with Rockwood type III or V ACJ dislocation were included. We found no differences in Constant–Murley score (SMD, − 0.58, 95% CI − 1.41 to 0.26; P = 0.18), American Shoulder and Elbow Surgeons score (SMD, 0.21, 95% CI − 0.10 to 0.52; P = 0.19), University of California at Los Angeles shoulder rating scale score (SMD, − 0.02, 95% CI − 1.27 to 1.23; P = 0.97), or VAS pain score (SMD, 0.36, 95% CI − 0.16 to 0.88; P = 0.17) between groups. The CC augmentation group had lower odds of osteolysis (OR, 0.27, 95% CI 0.10 to 0.74; P = 0.01) and a shorter CCD (SMD, − 0.29, 95% CI − 0.57 to − 0.01; P = 0.04).

Conclusion

HP fixation with CC augmentation is preferable for acute unstable ACJ dislocations. Although CC augmentation did not provide additional benefits related to functional outcomes or pain, it resulted in greater reduction maintenance after implant removal and a 73% lower risk of acromial osteolysis.

Trial registration

PROSPERO (CRD42021271118).