Different treatment strategies for acromioclavicular dislocation injuries: a nationwide survey on open/minimally invasive and arthroscopic concepts

A bibliometric analysis of the top 50 cited studies related to acromioclavicular joint instability

Background

Acromioclavicular joint (ACJ) injury is a common orthopaedic condition accounting for over 40 % of all shoulder injuries. The purpose of this study is to assess the research trends and characteristics of the top 50 cited articles on ACJ instability.

Methods

A systematic search was conducted in Web of Science to identify articles primarily related to ACJ injury or instability. Characteristics including citation number, country of origin, journal and institution of publication, impact factor, authorship, level of evidence, patient demographics, and study type were analyzed and recorded.

Results

Research output on ACJ instability has been steadily increasing, with the top 50 cited studies predominantly presenting Level IV evidence. These studies primarily focused on treatment outcomes which included predominantly male patients and exhibited a large variation in citation counts. The American Journal of Sports Medicine was the most productive journal, and the USA was the most productive nation.

Conclusion

There is an increasing number of publications in the ACJ instability literature, primarily concentrated in a few institutions and journals, and focusing mainly on treatment outcomes. A significant portion of these publications are of low scientific quality, and there is a notable lack of research on outcomes for females.

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.

[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.

Does the choice of the optic portal influence the radiographic and early functional results in acute acromioclavicular disjunctions?

Exposure of the coracoid process during arthroscopic stabilization of acute acromioclavicular disjunctions (ACDs) can be achieved either by passing an extra- articular optical portal through the subacromial space or by an intra-articular optical route through the glenohumeral joint with opening of the rotator interval. The objective of our study was to compare the impact on the functional results of these two optical routes. This was a retrospective, multicentre study that included patients operated on for an acute acromioclavicular disjunction arthroscopically. The treatment consisted of surgical stabilization under arthroscopy. The surgical indication was retained for an acromioclavicular disjunction of grade 3, 4 or 5, according to the Rockwood classification. Group 1, which consisted of 10 patients, was operated on with an extra-articular subacromial optical route, and group 2, which consisted of 12 patients, was operated on with an intra-articular optical route with opening of the rotator interval according to the habits of the surgeon. A follow-up of 3 months was performed. The functional results were evaluated for each patient using the Constant score, Quick DASH, and SSV. The delays in returning to professional and sports activities were also noted. A precise postoperative radiological analysis made it possible to analyse the quality of the radiological reduction. No significant difference between the two groups was found between the Constant score (88 vs. 90; p = 0.56), Quick DASH (7 vs. 7; p = 0.58), or SSV (88 vs. 93; p = 0.36). The times to return to work (6.8 weeks vs. 7.0 weeks; p = 0.54) and sports activities (15.6 weeks vs. 19.5 weeks; p = 0.53) were also comparable. The quality of the radiological reduction was satisfactory in the two groups and did not depend on the approach. No clinically or radiologically significant differences between the extra-articular and intra-articular optical portals in the surgical treatment of acute ACDs were found. The optical route can be chosen according to the habits of the surgeon.

Clinical and radiologic outcomes of the modified phemister procedure with coracoclavicular ligament augmentation using mersilene tape versus hook plate fixation for acute acromioclavicular joint dislocation

Background

The clinical superiority of surgical treatment for acromioclavicular (AC) joint dislocation remains controversial. The aim of this study was to compare the clinical and radiological outcomes of the modified Phemister procedure with CC ligament augmentation using Mersilene tape to those of hook plate fixation for acute AC joint dislocation.

Methods

In this study, patients who received modified Phemister surgery with CC ligament augmentation using Mersilene tape (PM group) or hook plate fixation (HK group) for acute unstable AC joint dislocation with a minimum 5-year follow-up period were retrospectively reviewed. The clinical outcomes were evaluated according to blood loss during surgery, surgical duration, visual analogue scale (VAS), Constant-Murley score (CMS), University of California at Los Angeles (UCLA) shoulder rating scale, and the occurrence of complications. Radiological outcomes were assessed from radiographs according to multiple parameters, including CC distance maintenance, acromion osteolysis, and the presence of distal clavicle osteolysis.

Results

A total of 35 patients completed follow-up for more than 5 years and were analyzed in this study (mean = 74.08 months). There were 18 patients in the PM group and 17 in the HK group. The PM group exhibited similar improvement in functional outcome to the HK group. Regarding radiological outcomes, the HK group had a superior performance in terms of CC distance maintenance, of statistical significance (CCDR: 94.29 ± 7.01% versus 111.00 ± 7.69%, p < 0.001) after a one-year follow-up period. However, there were 4 cases of acromion osteolysis and 2 cases of distal clavicle osteolysis in the HK group.

Conclusion

Hook plate fixation was found to be superior to the modified Phemister technique with CC ligament augmentation using Mersilene tape in terms of CC distance maintenance, but there was no significant difference in the functional outcome after 5 years of follow-up. Both surgical methods are reliable options for the treatment of acute AC joint dislocation. Modified Phemister surgery with CC ligament augmentation using Mersilene tape is a relatively lower-cost option for acute AC joint dislocation without the need of a second surgery for implant removal.

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.

No difference in clinical outcome at 2-year follow-up in patients with type III and V acromioclavicular joint dislocation treated with hook plate or physiotherapy: a randomized controlled trial

BACKGROUND

The need for operative treatment of acute acromioclavicular (AC) joint dislocation is unclear. The purpose of this randomized controlled trial was to compare the outcomes after operative treatment with a hook plate with the outcomes after nonoperative treatment of acute Rockwood type III and type V AC joint dislocations separately.

METHODS

The inclusion criteria were patients aged 18-65 years with an acute type III or type V AC joint dislocation with the availability to start treatment within 3 weeks after trauma. All patients received the same standardized outpatient rehabilitation protocol and were followed up for 24 months. Assessments were based on radiographs, clinical examination findings, and questionnaires. The primary outcome was the Constant score (CS). The secondary outcomes were as follows: Subjective Shoulder Value (SSV), QuickDASH score (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire), shoulder pain at rest and during movement rated using a visual analog scale, EQ-5D (European Quality of Life 5 Dimensions) score, patient satisfaction, cosmesis, complications, and adverse events. The 4 groups were compared using 1-way analysis of variance and intention to treat.

RESULTS

The included patients (N = 124) (mean age, 40 years [range, 18-64 years]; 91% male patients) were randomized, stratified by type, to nonoperative treatment (type III, n = 33; type V, n = 30) or operative treatment with a hook plate (type III, n = 30; type V, n = 31) at a single center. Three patients randomized to physiotherapy dropped out before any follow-up measures, leaving 121 patients in the study. Complete clinical follow-up data were obtained from 118 patients at 24 months. At 3 months, patients in both nonoperatively treated groups had a significantly better mean CS, SSV, and QuickDASH score and had less pain at rest and during movement compared with patients treated operatively. At 6, 12, and 24 months, there were no significant differences in the CS, SSV, QuickDASH score, pain, or EQ-5D score between the groups regardless of intervention. At 24 months, the mean CS was 88 for nonoperatively treated type III patients vs. 91 for operatively treated type III patients and was 90 vs. 91 for type V patients (P = .477). At final follow-up, patients had regained 97% of the mean CS comparing the uninjured and injured shoulders and 86% of the patients rated the result as excellent or good. Eleven patients assigned to nonoperative treatment (18%, 6 type III and 5 type V) underwent surgery within 19 months.

CONCLUSIONS

Both the nonoperative and operative treatment groups had very good restoration of shoulder function and patient satisfaction at 24 months, and operative treatment did not lead to better outcomes compared with nonoperative treatment. In conclusion, our study does not support surgery with a hook plate in patients with acute Rockwood type III or type V AC joint dislocations.

Three-dimensional morphometric analysis of the lateral clavicle and acromion: Implications for surgical treatment using subacromial support

Objectives:

Dislocations and periarticular fractures of the acromioclavicular joint are common injuries of the shoulder girdle. When surgical intervention is indicated, subacromial support is one option to restore the alignment between scapula and the distal/lateral clavicle. Devices used for subacromial support rely on a form of subacromial ‘hook’. The shape, inclination and orientation of which is often mismatched to the anatomy of the inferior surface of the acromion, which may lead to painful acromial osteolysis and rotator cuff abrasion causing impingement. The primary goal of this study was to characterize the geometrical parameters of the acromion and distal clavicle, and their orientation at the acromioclavicular joint.

Methods:

Computed tomography scans of 120 shoulders were converted into digital three-dimensional models. Measurements of the acromion inclination and acromion width relative to the torsional angle as well as the clavicle depth were taken. A numerical optimization of the anatomical parameters (including torsional and inclination angles, height and width) was performed to find the combination of those parameters with the lowest interpatient variability.

Results:

The mean clavicle depth was found to be 11.1 mm. The mean acromion width was 27 mm. The combination of torsional and inclination angles with lowest interpatient variability was found at 80° and 16°, respectively.

Conclusion:

There is a high interpatient variability in the morphology of the inferior surface of the acromion. Subacromial support using a ‘hook’ can be optimized for contact surface area, which should lead to fewer complications after the restoration of acromioclavicular orientation using acromial support strategies.

Monopolar and Bipolar Combination Injuries of the Clavicle: Retrospective Incidence Analysis and Proposal of a New Classification System

Clavicle injuries are common, but only few case reports describe combined clavicular injuries (CCI). CCI include combinations between clavicular fractures and acromioclavicular/sternoclavicular joint dislocations (SCJD). We present the first general therapeutic recommendations for CCI based on a new classification and their distribution. A retrospective, epidemiological, big data analysis was based on ICD-10 diagnoses from 2012 to 2014 provided by the German Federal Statistical Office. CCI represent 0.7% of all clavicle-related injuries (n = 814 out of 114,003). SCJD show by far the highest proportion of combination injuries (13.2% of all SCJD were part of CCI) while the proportion of CCI in relation to the other injury entities was significantly less (p < 0.023). CCIs were classified depending on (1) the polarity (monopolar type I, 92.2% versus bipolar type II, 7.8%). Monopolar type I was further differentiated depending on (2) the positional relationship between the combined injuries: Ia two injuries directly at the respective pole versus Ib with an injury at one end plus an additional midshaft clavicle fracture. Type II was further differentiated depending on (3) the injured structures: IIa ligamento-osseous, type IIb purely ligamentous (rarest with 0.6%). According to our classification, the CCI severity increases from type Ia to IIb. CCI are more important than previously believed and seen as an indication for surgery. The exclusion of further, contra-polar injuries in the event of a clavicle injury is clinically relevant and should be focused.

Free Hand Drilling Technique to Enhance Central Position of Tunnels in Arthroscopic Acromioclavicular Joint Fixation Using TightRope System

Acromioclavicular joint (ACJ) dislocations represent one of the most common lesions in the shoulder. Arthroscopic reduction and ACJ fixation with the button system is one of the most used techniques for displaced and unstable dislocations. Difficulties with placing the tunnels in the central and correct position of the clavicular and coracoid can occur with the use of a guide, which can result in fractures, eccentric tunnel position, cortical rupture, prolongation of surgical times with its complications as bleeding, tissue infiltration, difficult visualization, and increased risk of infection. Prior free hand central tunnel placement in the clavicle with a 3.2 mm drill helps to keep in place the pin guide over the superior cortical of coracoid with reduction of guide movement to enhance the correct position of tunnel in the coracoid process avoiding bone complications.

Acromioclavicular and sternoclavicular joint dislocations indicate severe concomitant thoracic and upper extremity injuries in severely injured patients

Preliminary studies show that clavicle fractures (CF) are known as an indicator in the severely injured for overall injury severity that are associated with relevant concomitant injuries in the thorax and upper extremity. In this regard, little data is available for the rarer injuries of the sternoclavicular and acromioclavicular joints (SCJ and ACJ, respectively). Our study will answer whether clavicular joint injuries (CJI), by analogy, have a similar relevance for the severely injured. We performed an analysis from the TraumaRegister DGU (TR-DGU). The inclusion criterion was an Injury Severity Score (ISS) of at least 16. In the TR-DGU, the CJI were registered as one entity. The CJI group was compared with the CF and control groups (those without any clavicular injuries). Concomitant injuries were distinguished using the Abbreviated Injury Scale according to their severity. The inclusion criteria were met by n = 114,595 patients. In the case of CJI, n = 1228 patients (1.1%) were found to be less severely injured than the controls in terms of overall injury severity. Compared to the CF group (n = 12,030; 10.5%) with higher ISS than the controls, CJI cannot be assumed as an indicator for a more severe trauma; however, CF can. Concomitant injuries were more common for severe thoracic and moderate upper extremity injuries than other body parts for CJI. This finding confirms our hypothesis that CJI could be an indicator of further specific severe concomitant injuries. Despite the rather lower relevance of the CJI in the cohort of severely injured with regard to the overall injury severity, these injuries have their importance in relation to the indicator effect for thoracic concomitant injuries and concomitant injuries of the upper extremity. A limitation is the collective registration of SCJ and ACJ injuries as one entity in the TR-DGU. A distorted picture of the CJI in favor of ACJ injuries could arise from the significantly higher incidence of the ACJ dislocation compared to the SCJ. Therefore, these two injury entities should be recorded separately in the future, and prospective studies should be carried out in order to derive a standardized treatment strategy for the care of severely injured with the respective CJI.

[Effectiveness of arthroscopic assisted double Endobutton "8" buckle fixation in treatment of Rockwood type acute acromioclavicular joint dislocation]

OBJECTIVE

To investigate the short-term effectiveness of arthroscopic assisted double Endobutton "8" buckle fixation in the treatment of Rockwood Ⅲ type acute acromioclavicular joint dislocation.

METHODS

The clinical data of 12 patients with Rockwood Ⅲ type acute acromioclavicular joint dislocation who were treated with arthroscopic assisted double Endobutton "8" buckle fixation between June 2016 and June 2019 were analyzed retrospectively. There were 8 males and 4 females, with an average age of 47.0 years (range, 36-58 years). There were 4 cases of left shoulder and 8 cases of right shoulder. The causes of injury included traffic accident injury in 7 cases and falling injury in 5 cases. The average time from injury to operation was 5.0 days (range, 3-14 days). Before operation and at last follow-up, the shoulder joint activity was recorded; the improvements of function and pain were evaluated by Constant score and visual analogue scale (VAS) score, respectively; the reduction was evaluated by measuring the coracoid spacing of the affected side on the anteroposterior X-ray film of shoulder joint.

RESULTS

All 12 cases were followed up 6-36 months, with an average of 20.6 months. All the incisions healed by first intention. There was no complications such as clavicle and coracoid fractures and Endobuton displacement. At last follow-up, the range of motion of the abduction improved from preoperative (77.5±4.5)° to (162.5±6.5)°, the range of motion of forward flexion improved from (84.1±5.2)° to (169.5±5.8)°, the Constant score improved from 42.5±2.3 to 92.4±2.3, the VAS score improved from 5.4±0.8 to 0.6±0.5, and the coracoid spacing reduced from (20.5±1.4) mm to (9.2±0.6) mm, all showing significant differences ( P<0.05).

CONCLUSION

Arthroscopic assisted double Endobutton "8" buckle fixation for the treatment of Rockwood Ⅲ type acute acromioclavicular joint dislocation is safe, less invasive, and quicker recovery. It can effectively alleviate shoulder pain, significantly improve the mobility of the shoulder joint, and achieve good short-term effectiveness.

Current practice in the management of acromioclavicular joint dislocations; a national survey in the Netherlands

Purpose

The aim of this study was to investigate current practice in the management of acromioclavicular joint dislocations in the Netherlands.

Methods

A 36-item literature-based and expert consensus survey was developed. If available, one orthopaedic and one trauma surgeon for every hospital (n = 82) in the Netherlands was asked to complete the online questionnaire. Only complete data sets were included in the analysis. Descriptive analysis was performed using SPSS.

Results

Of 149 invited surgeons, 106 (71%) fully completed the survey. The diagnosis of ACJ injury was mainly based on physical examination (91%) and radiographs (95%). The vast majority of patients with ACJ injuries was treated non-operatively. The decision for operative treatment was mainly based on the surgeon’s experience and available literature. Patient-related factors that contributed most to the decision to operate or not, were mainly functional needs and age. Cosmesis and gender contributed less to this decision. Rockwood II and III ACJ injuries were usually treated non-operatively, whereas Rockwood IV and V ACJ injuries were usually treated operatively. For primary and secondary operative treatment, a flexible implant was preferred over rigid fixation techniques. All respondents agreed that nonoperative treatment of Rockwood II ACJ injuries leads to satisfactory results and that secondary operative treatment is only rarely required. Also the majority of patients with Rockwood III ACJ injuries is treated non-operatively, although failure rates are considered higher.

Conclusion

This survey showed a significant individual variation on diagnosis and treatment strategies among surgeons in the Netherlands. The majority of the Dutch surgeons concern a flexible implant the best available technique for patients who require operative treatment.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01414-0) contains supplementary material, which is available to authorized users.