Acromioclavicular joint injuries: diagnosis, classification and ligamentoplasty procedures

External Rotation of the Shoulder against Resistance as a Clinical Sign to Aid in the Diagnosis of Acromioclavicular Injury

Introduction

Acromioclavicular joint (ACJ) injuries account for more than 40% of all sports-related shoulder injuries. Early and effective diagnosis is crucial with surgical intervention favored over non-operative management in high-grade injury. At present diagnosis is primarily by plain radiography with a clear lack of good clinical examination techniques. This study aims to describe external rotation against resistance (ERAR) as a means of ACJ injury assessment.

Case Report

This case report describes three patients who presented to a local tertiary hospital with sporting injuries. In all cases, plain radiography demonstrated ACJ injury. Patients performed ERAR with the elbow by the side and flexed to 90° to assess for increase in ACJ deformity and coracoclavicular (CC) distance. The cases reported include two acute and one chronic ACJ injury. In all cases, this physical examination technique resulted in increased ACJ deformity and CC distance. This examination technique was well tolerated in all patients. All three patients underwent operative fixation and achieved excellent clinical outcomes.

Conclusion

In our experience, external rotation of the shoulder against resistance is a well-tolerated examination technique which has demonstrated good clinical utility, aiding in the diagnosis of moderate to high-grade ACJ injury. While this clinical examination technique may aid in the diagnosis of high-grade ACJ injury, the authors strongly recommend further clinical and radiological confirmation before the diagnosis of acute traumatic shoulder injuries.

What are our patients asking Google about acromioclavicular joint injuries?-frequently asked online questions and the quality of online resources

Background

Management of acromioclavicular (AC) joint injuries has been an ongoing source of debate, with over 150 variations of surgery described in the literature. Without a consensus on surgical technique, patients are seeking answers to common questions through internet resources. This study investigates the most common online patient questions pertaining to AC joint injuries and the quality of the websites providing information.

Hypothesis

1) Question topics will pertain to surgical indications, pain management, and success of surgery and 2) the quality and transparency of online information are largely heterogenous.

Methods

Three AC joint search queries were entered into the Google Web Search. Questions under the "People also ask" tab were expanded in order and 100 results for each query were included (300 total). Questions were categorized based on Rothwell's classification. Websites were categorized by source. Website quality was evaluated by the Journal of the American Medical Association (JAMA) Benchmark Criteria.

Results

Most questions fell into the Rothwell Fact category (48.0%). The most common question topics were surgical indications (28.0%), timeline of recovery (13.0%), and diagnosis/evaluation (12.0%). The least common question topics were anatomy/function (3.3%), evaluation of surgery (3.3%), injury comparison (1.0%), and cost (1.0%). The most common websites were medical practice (44.0%), academic (22.3%), and single surgeon personal (12.3%). The average JAMA score for all websites was 1.0 ± 1.3. Government websites had the highest JAMA score (4.0 ± 0.0) and constituted 45.8% of all websites with a score of 4/4. PubMed articles constituted 63.6% (7/11) of government website. Comparatively, medical practice websites had the lowest JAMA score (0.3 ± 0.7, range [0-3]).

Conclusion

Online patient AC joint injury questions pertain to surgical indications, timeline of recovery, and diagnosis/evaluation. Government websites and PubMed articles provide the highest-quality sources of reliable, up-to-date information but constitute the smallest proportion of resources. In contrast, medical practice represents the most visited websites, however, recorded the lowest quality score. Physicians should utilize this information to answer frequently asked questions, guide patient expectations, and help provide and identify reliable online resources.

Physiotherapeutic Management for Acromioclavicular Joint Sprain With Volar Intercalated Segment Instability at the Wrist: A Case Report

Among sports enthusiasts and young individuals, acromioclavicular (AC) joint injuries are highly prevalent. In this, we discussed the comprehensive assessment and management of a 22-year-old male patient who is a student by occupation and a recreational badminton player who presented with left shoulder and wrist pain following a road traffic accident. The study highlights the clinical findings, diagnostic assessment, and therapeutic interventions for the patient with volar intercalated segment instability and a grade 1 AC joint sprain. The methodology involves a case report of the patient's clinical evaluation, including range of motion, manual muscle testing, and diagnostic imaging. The patient was managed conservatively with physiotherapy interventions, including Mulligan's movement with mobilization, cryotherapy, light amplification by stimulated emission of radiation, and progressive exercises. The results of the study demonstrate the successful implementation of a multidisciplinary conservative management approach for alleviating pain, restoring function, and promoting optimal recovery for the patient. The implications of the study underscore the significance of tailored physical therapy rehabilitation in the management of AC joint sprains and wrist instabilities.

Double figure of eight technique using fiber tape for acute high-grade acromioclavicular joint dislocations - Reconstruction technique

Acromioclavicular (AC) joint dislocations are not uncommon injuries. High-grade dislocations can be managed by arthroscopic as well as open techniques, but the most important thing is to address both vertical and horizontal stability. The purpose of this study is to evaluate the functional outcome of a cost effective double figure of eight technique of stabilizing both coracoclavicular and acromioclavicular ligaments in acute high-grade disruption (Type IIIB -VI) using fibre tape. This study was performed at our tertiary care centre from 2017 to 2020 after appropriate IRB approval and patient consent. Out of 134 cases, 23 high-grade AC joint disruptions treated with our technique were included in the study. Demographic data analysis, pre-op and post-op Constant score and UCLA scoring were done to assess the functional outcome; Coracoclavicular distance (CCD) and CCD ratio were used to assess the radiological outcome. Significant improvement in Constant and UCLA shoulder scores were observed from pre-op to final follow up. With respect to the radiological outcome, all cases had a significant improvement in CCD and CCD ratio from baseline to final follow-up. To conclude, our double figure of eight technique is more anatomical, addresses both vertical and horizontal stability, easily reproducible, cost-effective and safe technique.

Current Concepts in Management of Acromioclavicular Joint Injury

Background: The management of acromioclavicular joint injuries requires a thorough understanding of the anatomy and biomechanics of the joint, as well as knowledge of the pertinent physical exam findings and classification to determine an appropriate treatment approach, whether operative or nonoperative. In this article, we present a narrative review of the current state of understanding surrounding these issues. Although there are a large number of options for operative intervention, we additionally present our experience with anatomic coracoclavicular ligament reconstruction (ACCR) with imbrication of the deltoid fascia. Methods: A retrospective review of prospectively collected data on a total of 45 patients who had undergone ACCR between 2003 and 2016 were collected. Results: We found that improvements were seen in American Shoulder and Elbow Surgeons Score (ASES) (53 ± 19 to 81 ± 23), Simple Shoulder Test (SST) (6 ± 3 to 12 ± 13), Constant-Murley (CM) (60 ± 18 to 92 ± 8), and Rowe (67 ± 14 to 89 ± 11) and the mean post-operative SANE score was 86 ± 17. Conclusions: ACCR has the advantage of addressing both horizontal and vertical stability with good outcomes.

Acromioclavicular joint separation: Controversies and treatment algorithm

In this article, we present an uptodate outline of acromioclavicular (AC) joint separation. A clear understanding of acromioclavicular joint injury in terms of the mechanism of injury, clinical picture, diagnostic imaging, and most updated surgical techniques used for the treatment can provide the best care for those patients. This article describes updated treatment strategies for AC separation, including type III AC separation which is known most controversial. Finally, we present a proposed treatment algorithm that can aid in the treatment of AC separation from the most updated evidence.

Management of Acromioclavicular Joint Injuries: A Historic Account

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

Acromioclavicular Joint Lesions in Adolescents-A Systematic Review and Treatment Guidelines

True acromioclavicular joint (ACJ) injuries are rare in children and adolescents due to the strength of ligaments in this age group. However, a standardized management guideline for these injuries is currently lacking in the literature. This systematic review aims to provide an organized overview of associated injuries and propose a management algorithm for pediatric ACJ injuries. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was conducted. Two independent observers searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus databases for ACJ injuries in children and adolescents. The extracted data were analyzed (due to the limited number of publications and inhomogeneity of data, no formal statistical analysis was conducted), and cases were categorized based on injury frequency and pattern, leading to the formulation of a treatment algorithm. The risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A total of 77 articles were identified, and 16 articles (4 case series and 12 case reports) met the inclusion criteria. This study included 37 cases in 36 patients (32 males, 4 females) with a mean age of 13 years (9-17 years). Six injury categories were described. Surgical management was performed in 27 ACJ injuries (25 open, 2 arthroscopic). Various surgical implants were used including K wires, polydioxanone sutures (PDS), screws, hook plates, suture anchors, and suture button devices. Most cases achieved good to excellent outcomes, except for one case of voluntary atraumatic dislocation of the ACJ. This systematic review provides the first comprehensive analysis of ACJ injury management in adolescents with open physis. It categorizes injury patterns and presents a treatment algorithm to enhance the understanding of these injuries. The review's findings contribute valuable insights for clinicians dealing with pediatric ACJ injuries.

Anatomical acromioclavicular joint stabilization with chemically sterilized tendon allografts: A retrospective study

Background

The purpose of this retrospective study was to analyze whether chemically sterilized tendon allografts perform as well as other non-sterilized allografts and autografts as described in the literature for anatomical acromioclavicular joint stabilization for the treatment of Rockwood III-V. Allografts are still described as a factor for higher re-rupture rates.

Methods

Retrospective data were collected from 21 acromioclavicular joint stabilizations performed by a single surgeon and performed between 2011 and 2014 using sterilized semitendinosus allografts. The primary endpoints were re-rupture and complication rates. Secondary endpoints were AC-joint stability, pain level, return to work and sport and the range of motion.

Results

No re-ruptures occurred during the mean follow-up time of 33 months. Zero complications occurred directly after surgery, but three complications later than three weeks after surgery. All cases resolved without further surgery. After surgery, stability significantly improved for all patients. Post-surgery, 19 patients had stable acromioclavicular joints and only two patients showed minor instabilities. Range of motion returned to the range of the healthy shoulders for all patients.

Conclusion

Chemically sterilized semitendinosus allograft use for anatomic AC-joint stabilization is equivalent to the use of other allografts or autografts and required no hardware removal. No donor age or graft size dependence was observed, due to zero re-ruptures.

Discrimination between falls and blows from the localization and the number of fractures on computed tomography scans of the skull and the trunk

The distinction between falls and blows is a common and difficult task in forensic sciences. One of the most often used criteria to address this issue is the hat brim line (HBL) rule, which states that fall-related injuries do not lie above the HBL. Some studies, however, have found that the use of HBL rule is not so relevant. This study assesses the aetiologies, the number of fractures, and their location on the skull and the trunk in a sample of 400 individuals aged 20-49 years, which were CT scanned after traumas. This may facilitate the interpretation of such injuries in skeletonized or heavily decomposed bodies in which soft tissues are no longer available. Our aim is to improve the distinction rate between falls and blows by combining several criteria and assessing their predictability. Skeletal lesions were analysed using retrospective CT scans. Cases selected comprise 235 falls and 165 blows. We registered the presence and the number of fractures in 14 skeletal anatomical regions related to the two different aetiologies. We showed that the HBL rule should be used with caution, but there is nevertheless a possibility of discussing the aetiology of blunt fractures. Possibly, parameters like the anatomical location and the number of fractures by region can be used to distinguish falls and blows.

Acromioclavicular Joint Injuries in Sport

ABSTRACT

Sport-related shoulder injuries, including disruptions to the acromioclavicular joint (ACJ), are common. An ACJ injury is classified by the degree and direction of the clavicle displacement. Although the diagnosis can be made clinically, standard radiographic views are important to determine the severity of the ACJ disruption and assess for concurrent injuries. The majority of ACJ injuries can be managed nonoperatively; however, surgical treatment is indicated in some cases. Long-term outcomes are generally favorable for most ACJ injuries, and athletes generally return to sport without functional limitations. This article provides an in-depth discussion regarding all aspects of ACJ injuries, including clinically relevant anatomy, biomechanics, evaluation, treatment, and complications.

JOINT INJURIES IN MARTIAL ARTS AND THEIR PREVENTIVE MEASURES

ABSTRACT Introduction: Martial arts athletes are highly prone to joint injuries during training or sports events. These injuries can affect professional performance and cause deleterious psychological damage to athletes. Objective: Explore the current status of joint injuries in martial arts and propose effective preventive measures. Methods: Martial arts athletes were selected to evaluate the types of joint injuries and the method of training in rehabilitating these injuries (n=32). They were randomly divided into an experimental group and a control group. The experimental group received a specific functional preventive training protocol based on updated scientific findings, while the control group received traditional physical training. Range of motion and functional FMS tests were performed before and after the interventions. The results were compared statistically. Results: The most common type of injury for athletes in martial arts is joint injury, followed by ligament and synovial inflammation. The probability of a joint injury rises when athletes are in continuous action training; the FMS test results of the athletes in the experimental group were significantly improved, with a very significant effect. Conclusion: The preventive functional training proposed in this paper can improve athletes’ fitness, improve coordination and joint stability, and prevent sports injuries. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

Delayed acromioclavicular joint reconstruction using a modern suspensory device does not increase the risk of fixation failure or major complications

BACKGROUND

Management of displaced acromioclavicular joint (ACJ) injuries remains contentious. It is unclear if delayed vs. acute reconstruction has an increased risk of fixation failure and complications. The primary aim of this study was to compare complications of early vs. delayed reconstruction. The secondary aim was to determine modes of failure of ACJ reconstruction requiring revision surgery.

METHODS

A retrospective study was performed on all patients who underwent operative reconstruction of ACJ injuries over a 10-year period (Rockwood III-V) using suspensory devices with or without hamstring allograft. Reconstruction was classed as early (<12 weeks from injury) or delayed (≥12 weeks). Patient demographics, fixation method, and postoperative complications were noted, with 1-year follow-up a minimum requirement for inclusion. Patient-reported outcomes with the Disabilities of the Arm, Shoulder, and Hand score and EuroQol-5 Dimension were undertaken. Fixation failure was defined as loss of reduction requiring revision surgery.

RESULTS

A total of 104 patients were analyzed (n = 59 early and n = 45 delayed). The mean age was 42.0 (standard deviation: 11.2; 17-70 years); 84.6% were male and 15.4% were smokers. No difference was observed between fixation failure (P = .39) or deep infection (P = .13) with regard to acute vs. delayed reconstruction. No patient demographic or timing of surgery was predictive of fixation failure on regression modeling. Overall, 11 patients underwent revision surgery for loss of reduction and implant failure (n = 5 suture fatigue, n = 2 endobutton escape, n = 2 coracoid stress fracture, and n = 2 deep infection). The EuroQol-5 Dimension (P = .084) and Disabilities of the Arm, Shoulder, and Hand score (P = .062) were comparable for early and delayed groups respectively and below the minimal clinically important difference.

CONCLUSION

This study found that delayed surgical management of ACJ injuries using a modern device has comparable functional outcomes and is not associated with a higher incidence of fixation failure or major complications.

The Outcomes of Three Surgical Approaches for Acromioclavicular Dislocation Treatment: Findings from Vietnam

Background: Acromioclavicular (AC) dislocation, one of the most common shoulder joint injuries, can be treated by several surgical methods. However, there are still few records about the treatment quality. This study aims to describe the outcomes of three surgical methods for acromioclavicular dislocation treatment at Viet Duc University Hospital, Vietnam. Methods: A cross-sectional study was conducted on 80 patients diagnosed with AC. We retrospectively collected data in the medical records and re-examined the patients. Results: There was no difference between the three groups of surgical approaches relating to the patient’s characteristics, except for the time from the accident to hospital admission. The median length of stay after surgery was highest in the Hook plate group (median (IQR) = 5(2) days), while it was lowest in the K-wire group (median (IQR) = 3(1) days) (p < 0.05). There is statistical significance in the difference of coracoclavicular distance between pre and post-operation in all three surgical method groups (p < 0.001). Conclusion: All of the methods—Hook plate, K-wire, and TightRope—were associated with optimistic outcomes and restored initial anatomy. While the three surgical methods are both safe and effective, the K-wire method is associated with a shorter length of stay and might be economical.

Acromioclavicular Joint Injury and Repair

The acromioclavicular (AC) joint is commonly injured in athletes participating in contact and overhead throwing sports. Injuries range from simple sprains to complete ligamentous disruption, and they are classified by the established Rockwood grading system. High-grade injuries are associated with fractures around the AC joint and disruption of the superior shoulder suspensory complex, a ring of osseous and ligamentous structures at the superior aspect of the shoulder. Radiographs are the mainstay of imaging of the AC joint, with magnetic resonance imaging reserved for high-grade injuries to aid classification and plan surgical management. Low-grade AC joint injuries tend to be managed conservatively, but a wide range of surgical procedures have been described for higher grade injuries and fractures around the AC joint. This review illustrates the anatomy of the AC joint and surrounding structures, the imaging features of AC joint injury, and the most commonly performed methods of reconstruction and their complications.

Horizontal instability after acromioclavicular joint reduction using the two-hole technique is preferred over the loop technique: a single-blind randomized clinical trial

Background

Most acromioclavicular joint (ACJ) injuries are caused by direct trauma to the shoulders, and various methods and techniques are used to treat them; however, none of the options can be considered the gold standard. This study examines the horizontal stability of the ACJ after a complete dislocation was repaired using one of two Ethibond suture techniques, the loop technique and the two holes in the clavicle technique.

Methods

In this single-blind, randomized clinical trial, 104 patients diagnosed with complete ACJ dislocation type V were treated using Ethibond sutures with either the loop technique or the two holes in the clavicle technique. Horizontal changes in the ACJ were radiographically assessed in the lateral axial view, and shoulder function was evaluated by the Constant (CS) and Taft (TS) scores at intervals of 3, 6, and 12 months after surgery.

Results

The horizontal stability of the ACJ was better with the two-hole technique than the loop technique at all measurement times. CS and TS changes showed a significant upward trend over time with both techniques. The mean CS and TS at the final visit were 95.2 and 11.6 with the loop technique and 94.0 and 11.9 with the two-hole technique, respectively. The incidence of superficial infections caused by the subcutaneous pins was the same in the two groups.

Conclusions

Due to the improved ACJ stability with the two-hole technique, it appears to be a more suitable option than the loop technique for AC joint reduction.

Managing acute acromioclavicular joint dislocation during COVID 19 pandemic by minimally invasive technique with suture anchor and miniplate: A pilot study

Background

Acromioclavicular (AC) joint dislocation is common in sportsmen and physically active population. Its management depends upon the grade of injury and functional demands of the patient. A variety of surgical procedures have been described with different limitations and advantages. The present study has assessed the clinical and radiological outcome of acute AC joint dislocation managed with a 3.5 mm Titanium suture anchor and 2 mm miniplate construct which requires lesser dissection, surgical time and thus contact with the patient as mandated by COVID-19 pandemic.

Methods

We enrolled 10 patients of Rockwood type-III, IV and V acute AC joint injury (<3 weeks old) reporting at this hospital from Feb 2020 to May 2021. All were tested for COVID-19 using reverse transcriptase polymer chain reaction test (RTPCR) and managed by closed/open reduction and fixation with a 3.5 mm Titanium Suture Anchor and a 2 mm Titanium miniplate construct. Follow-up was done at 3, 6 and 9 month post-operatively.

Results

The average age of patients was 31 yrs. RTPCR test for COVID-19 was negative in all patients. Median surgical time was 25 min (Interquartile Range[IQR] = 16-34 min) and median follow-up duration was 36 weeks (IQR = 33-39 weeks). Median visual analogue scale score and IQR at pre-operative, 3 month, 6 month and 9 month follow-up was 7(IQR = 6-8), 3.5(IQR = 2.5-4.5), 2(IQR = 0) and 1(IQR = 0), respectively. Median constant score at pre-operative, 3 month, 6 month and 9 month follow-up were 34(IQR = 25-43), 65.5(IQR = 60.5-70.5), 82.5(IQR = 77.5-87.5) and 88(IQR = 81-95). There was significant improvement in clinical status (non parametric-Friedman test p < 0.001). Radiographs showed no loss of reduction, fracture or implant failure till last follow-up.

Conclusions

Minimally invasive technique with a 3.5 mm Ti-suture anchor and 2 mm plate is an easy, fast and reliable construct for the management of acute AC dislocation in physically active population.

Is coracoclavicular ossification a complication or a good prognostic factor after surgical treatment of acromioclavicular joint injury?

Background

The purpose of this study was to investigate whether heterotopic ossification (HO) in the coracoclavicular (CC) space after surgical treatment of acromioclavicular joint (ACJ) injury is a complication or a sign of good prognosis.

Methods

Fifty-nine consecutive patients who underwent CC reconstruction with or without augmentation of the ACJ for acute ACJ injuries were analyzed. Postoperative American Shoulder and Elbow Surgeons (ASES) score, Constant score (CS), subjective shoulder value (SSV), and visual analog scale (VAS) results were evaluated. For radiological evaluation, HO was evaluated, and CC distances were measured.

Results

Fifty-one patients (11 women and 40 men; mean age, 36 years [range, 17-68 years]) were evaluated after a mean follow-up of 3 years (range, 2-8 years). The mean ASES score at the follow-up was 82.73 (range, 51.6-100), mean CS was 85 (range, 50-100), mean SSV was 80 (range, 40-100), and mean VAS was 1.9 (range, 0-5). It was observed that the clinical outcomes (ASES, CS, SSV, VAS) of patients who developed ossification in the CC space were better than those who did not although it was not statistically significant. No statistically significant differences were found in the clinical outcomes (ASES, CS, SSV, VAS) between patients who underwent CC reconstruction without augmentation of the ACJ and those who were combined (P > .05).

Conclusion

HO in the CC space is a common finding following AC joint fixation injury. We suggest that HO is not a complication and might possibly have positive effects on clinical outcomes.

Occult clavicle osteomyelitis caused by Cutibacterium acnes (C. acnes) after coracoclavicular ligament reconstruction: A case report and review of the literature

INTRODUCTION

Clavicle osteomyelitis is a rare, but serious complication following operative repair of acromioclavicular (AC) joint separations. Cutibacterium Acnes (C. acnes) is rarely a causative pathogen in clavicle osteomyelitis and diagnosis can be challenging due to the indolent nature of this organism.

CASE PRESENTATION

A 45-50 year old female with a chronic AC joint separation underwent an open coracoclavicular reconstruction using semitendinosus allograft and FiberTape (Arthrex, Naples, FL). At the six month follow up, the patient complained of mild persistent pain. Imaging demonstrated widening of the medial suture tunnel with distal clavicle osteolysis, which was concerning for osteomyelitis. This was successfully treated with implant removal revision surgery and additional intravenous antibiotics. Cultures of the graft material were positive for C. acnes. The patient continued to have osteolysis of the distal left clavicle for a period of time despite resolution of osteomyelitis.

DISCUSSION

C. acnes osteomyelitis of the clavicle is difficult to diagnose because of its vague associated symptoms when implicated in infections. There are no known obvious predisposing factors for C. acnes clavicle osteomyelitis. Literature suggests management should include aggressive irrigation and debridement, removal of any hardware, and extended intravenous antibiotic administration.

CONCLUSION

C. acnes clavicular osteomyelitis is uncommon, thus established treatment guidelines have not yet been formed. Revision surgery to remove graft material, irrigate, and debride in addition to antibiotic treatment was successful for our patient. Additional pathologic manifestations of C. acnes infections could include continued clavicular erosion post-clearance of infection, although further investigation is necessary.

Single tunnel technique versus coracoid sling technique for arthroscopic treatment of acute acromioclavicular joint dislocation

To evaluate and compare the efficacy of two techniques for the treatment of acute acromioclavicular joint dislocation, the charts of 60 patients diagnosed with acute Rockwood type IV and V acromioclavicular joint dislocation that undergone arthroscopic fixation procedure with single tunnel technique (N = 30, 30.7 ± 5.7 years old) or coracoid sling technique (N = 30, 30.1 ± 5.4 years old) fixation were retrospectively reviewed. The Visual Analog Scale pain score, Constant shoulder functionality score, Karlsson acromioclavicular joint score, the time of return to sports and activity, and plain radiographs of the affected shoulder at different time points of follow-up were recorded for a minimum of 2 years post-op. The majority of the patients recovered to their preoperative activity levels with few complications. The average postoperative acromioclavicular and coracoclavicular distances were significantly narrower than preoperative measurements in both groups without significant difference between the two groups at 2 years post-op (P < 0.05). The coracoid sling technique group had reduced operative time, shorter time of recovery of shoulder movements, higher Constant functionality scores and Karlsson acromioclavicular joint scores, and fewer complications than the single tunnel technique group at the last follow-up (P < 0.05). Therefore, coracoid sling technique achieved superior clinical outcomes with fewer complications compared to the traditional single tunnel technique in arthroscopic treatment of acute acromioclavicular joint dislocation.

Modified Weaver-Dunn Technique Using Transosseous Bone Tunnels and Coracoid Suture Augmentation

INTRODUCTION

A modified Weaver-Dunn procedure for the management of acromioclavicular joint injuries that uses transosseous bone tunnels and coracoid suture augmentation is described with associated clinical results.

METHODS

A retrospective review of 39 consecutive patients who underwent a primary mWD procedure by a single surgeon from January 2013 to July 2019 was conducted. Patient charts and radiographs were reviewed for clinical course, complications and management, and radiographic evaluation. Satisfaction, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Simple Shoulder Test scores were obtained.

RESULTS

A total of 28 patients (72%) with a mean follow-up of 37.5 (12 to 84 months) and a mean age of 44.3 ± 15.1 years were included. Postoperative ASES, Simple Shoulder Test, Single Assessment Numeric Evaluation, and satisfaction scores were 90.6 ± 14.2, 11.1 ± 1.5, 87.3 ± 10.2, and 4.4 ± 1.2 (out of 5), respectively, with a significant improvement in ASES of 42.2 ± 21.8 points (P < 0.001). All patients had significant decrease in coracoclavicular distance (P < 0.001). Three patients (10.7%) had complications, with two (7.1%) requiring additional surgery.

CONCLUSION

Excellent functional and radiographic outcomes can be achieved with this modified Weaver-Dunn technique. Complication and revision rates are comparable with those that are found in the literature.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Low rate of substantial loss of reduction immediately after hardware removal following acromioclavicular joint stabilization using a suspensory fixation system

PURPOSE

To evaluate immediate loss of reduction in patients undergoing hardware removal after arthroscopically assisted acromioclavicular (AC) joint stabilization using a high-tensile suture tape suspensory fixation system and to identify risk factors associated with immediate loss of reduction.

MATERIALS AND METHODS

Twenty-two consecutive patients with a mean age of 36.4 ± 12.6 years (19-56), who underwent hardware removal 18.2 ± 15.0 months following arthroscopically assisted stabilization surgery using a suspensory fixation system for AC joint injury between 01/2012 and 01/2021 were enrolled in this retrospective monocentric study. The coracoclavicular distance (CCD) as well as the clavicular dislocation/acromial thickness (D/A) ratio were measured on anterior-posterior radiographs prior to hardware removal and immediately postoperatively by two independent raters. Loss of reduction, defined as 10% increase in the CCD, was deemed substantial if the CCD increased 6 mm compared to preoperatively. Constitutional and surgical characteristics were assessed in a subgroup analysis to detect risk factors associated with loss of reduction.

RESULTS

Postoperatively, the CCD significantly increased from 12.6 ± 3.7 mm (4.8-19.0) to 14.5 ± 3.3 mm (8.7-20.6 mm) (p < 0.001) while the D/A ratio increased from 0.4 ± 0.3 (- 0.4-0.9) to 0.6 ± 0.3 (1.1-0.1) (p = 0.034) compared to preoperatively. In 10 cases (45%), loss of reduction was identified, while a substantial loss of reduction (> 6 mm) was only observed in one patient (4.5%). A shorter time interval between index stabilization surgery and hardware removal significantly corresponded to immediate loss of reduction (11.0 ± 5.6 vs. 30.0 ± 20.8 months; p = 0.007), as hardware removal within one year following index stabilization was significantly associated with immediate loss of reduction (p = 0.027; relative risk 3.4; odds ratio 11.67).

CONCLUSIONS

Substantial loss of reduction after hardware removal of a high-tensile suture tape suspensory fixation system was rare, indicating that the postoperative result of AC stabilization is not categorically at risk when performing this procedure. Even though radiological assessment of the patients showed a statistically significant immediate superior clavicular displacement after this rarely required procedure, with an increased incidence in the first year following stabilization, this may not negatively influence the results of ACJ stabilization in a clinically relevant way.

LEVEL OF EVIDENCE

IV.

Anchorless Acromioclavicular and Coracoclavicular Ligament Repair Using a Graft-Passing Instrument to Pass Suture Under the Coracoid

Acromioclavicular joint separation is a common shoulder injury. Grade I and II separation may be treated nonoperatively, whereas higher grades tend to require surgical intervention. Various repair techniques have been described in the literature, with no consensus on the gold standard. This Technical Note describes our use of a graft-passing instrument to pass suture under the coracoid during an anatomic reconstruction of both the acromioclavicular and coracoclavicular ligaments. Although this approach is technically challenging, it avoids coracoid drilling and requires smaller-diameter clavicle and acromion drilling. Furthermore, using suture instead of graft material increases the cost-effectiveness of the procedure.

Acromioclavicular Joint Reconstruction with Recessed Clavicular Implant Technique Guide

Acromioclavicular (AC) joint injuries are common and often require operative intervention. Although there are many described surgical techniques, there remains a lack of consensus on the optimal technique. The purpose of this Technical Note is to provide our preferred method of AC reconstruction with a recessed clavicular implant and semitendinosus allograft, which mitigates hardware pain associated with arthroscopic techniques.

Anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon allograft is effective for chronic acromioclavicular joint injuries at mid-term follow-up

PURPOSE

To evaluate the clinical and radiographic outcomes of patients undergoing anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon allografts for the treatment of chronic acromioclavicular joint (ACJ) injuries with a minimum 1-year follow-up.

METHODS

Patients who underwent ACCR for chronic ACJ injuries between 2003 and 2017 were analyzed. Clinical outcome measures included American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CM), Simple Shoulder Test (SST), and Single Assessment Numerical Evaluation (SANE) scores. Radiographic loss of reduction during follow-up was evaluated by calculating the difference (mm) in the coracoclavicular distance (CCD) of the involved side immediately postoperatively and at terminal follow-up.

RESULTS

Forty-two patients (mean age: 42.7 ± 12.8 years) were included in the study with an average follow-up of 3.8 ± 3.1 years (range: 1.1-11.5 years). Patients achieved significant improvement in ASES (50.2 ± 20.1 pre to 85.2 ± 16.3 post), CM (60.2 ± 18.5 pre to 88.2 ± 9.1 post), SST (6.1 ± 3.2 pre to 9.5 ± 3.7 post), and SANE (24.0 ± 25.7 pre to 89.0 ± 12.7 post) scores (P < 0.001, respectively). There were no significant differences in functional improvement when comparing type III and V injuries (n.s.). Mean increase in CCD of the involved side from immediately postoperative to final radiographic follow-up was 4.1 ± 3.9 mm, with no significant correlation to clinical outcomes scores. Complications occurred in 33.3% of cases, with postoperative heterotopic ossification being most frequent (14.3%).

CONCLUSION

Patients undergoing ACCR using free tendon allografts for chronic ACJ injuries achieved significant improvement in shoulder function at a mean follow-up of 3.8 years. No correlation was observed between the amount of loss of reduction and clinical outcome scores. Free tendon allografts may be a reliable alternative to autografts in the treatment of chronic ACJ dislocations.

LEVEL OF EVIDENCE

IV.

Influential factors of subacromial impingement syndrome after hook plate fixation for acromioclavicular joint dislocation: A retrospective study

Subacromial impingement syndrome (SIS) after hook plate fixation for acromioclavicular joint (AC) dislocation was the most common complication. However, the researches on its' influential factors were rare. The purpose of this study was to identify the risk factors by analyzing the influencing factors of postoperative SIS and minimize the incidence of SIS in clinical surgery.We retrospectively analyzed the prospectively collected data from 330 consecutive patients with AC joint dislocation between August 2014 and August 2017 at our institute. The SIS was presented as the dependent variable at the last follow-up when the internal fixation was removed. The independent variables included age, gender, body-mass index (BMI), smoking status, alcohol consumption, type of injury, Rockwood Classification, site of injury, operation time, injury-to-surgery, the distance between the hook body and the acromion (DBA), the depth of hook tip (DHT), the distance between the hook plate and the humeral head (DHH), the distance between the acromion and the humeral head (DAH), the hook plate angle (AHP) and acromial shape. Logistic regression analysis was performed to identify independent influential factors of SIS.A total of 312 cases were included and 18 cases were lost. The follow-up rate was 94.5%. In without SIS group, there were 225 cases (123 males and 102 females). In with SIS group, a total of 87 cases were included (56 males and 31 females). The incidence of SIS was 27.8%. DHT (OR = 9.385, 95% CI = 4.883 to 18.040, P < .001) and DBA (OR = 2.444, 95% CI = 1.591 to 3.755, P < .001) were the significant independent risk factor for SIS of AC dislocation treat with hook plate. DAH (OR = 0.597, 95% CI = 0.396 to 0.900, P = .014) and acromial shape with flat and straight (OR = 0.325, 95% CI = 0.135 to 0.785, P = .012) were also independent factors of SIS, but they were all protective.The SIS had a high incidence in fixation of clavicular hook plate for AC dislocation. DHT and DBA were two independent risk factors, DAH and acromial shape with flat and straight were two independent protective factors for SIS. In clinical surgery, we should avoid risk factors to reduce the incidence of SIS.

Outcomes of acromioclavicular joint dislocation using tightrope arthroscopy

BACKGROUND

Based on different treatment outcomes and different treatment methods for acromioclavicular dislocation, we decided to evaluate the treatment outcomes of acromioclavicular joint dislocation using tightrope arthroscopy.

METHODS

This retrospective cross-sectional study was performed on patients with acromioclavicular joint dislocation referred to Alzahra Hospital in Isfahan and Abadan-Iran from 2015 to 2017. Information that was assessed included age, sex, type of dislocation (Figure 1), duration of injury, cause of injury, complications such as osteoarthritis, changes in the distance between the joints, as well as the American Shoulder and Elbow Surgeons Shoulder Score (ASES) were collected after 6 months of surgery.

RESULTS

There was a significant relationship between horizontal change instability and type of injury that 9 cases (60%) of type 5 of injury and 0 of type 3 had horizontal change instability (P=0.01). There was a reverse significant correlation between ASES score and duration of injury (r=-0.58, P=0.01).

CONCLUSION

Acromioclavicular joint dislocations could successfully be treated with the TightRope system. We also showed that patient's pain and functions are diversely correlated with injury durations.

Mini open triple tunnel- double flip button techniques in treatment of acute acromioclavicular joint injuries: Case report

Acute acromioclavicular (AC) joint injuries are common and often occur in a contact sport activity. Most acute AC joint injuries surgery techniques focus on coracoclavicular (CC) ligament complex fixation; by single or double clavicle tunnel, but persisting vertical instability. In this paper, we introduce mini open triple tunnel- double flip button (TTDB) technique for acute AC joint dislocation by adding tunnel on clavicle to expand coverage of footprint of conoid and trapezoid ligament in order to improve vertical stability of the AC joint. This method is based on CC ligament augmentation with a double flip button/polydioxanone (PDS), combined with V-loop pulley suture for anatomical fixation. This is a prospective case report. Two professional, male basketball players in this study with a mean age of 25 years underwent surgery in 2019. Clinical subjective outcome, VAS score, Nottingham Clavicle Score, and radiological CC distance were measured before and after the operation. There were noticeable improvement in the patients' recovery after two years since the operation. We introduce TTDB technique as one of the open techniques for acute AC joint injuries in limited-resource hospital setting.

Comparison between hook plate fixation with and without coracoclavicular ligament suture for acute acromioclavicular joint dislocations

BACKGROUND

Hook plates are widely used for repair of acromioclavicular joint (ACJ) dislocations. However, it is unclear whether repair of torn coracoclavicular (CC) ligament is necessary. The purpose of this study was to evaluate the outcomes of the hook plate fixation with direct CC ligament repair for acute ACJ dislocation in comparison with the hook plate fixation without direct CC ligament repair.

METHODS

The study included 120 patients with acute ACJ dislocations who underwent surgery. The patients were divided into 73 patient groups with Arbeitsgemeinschaft für Osteosynthesefragen (AO) hook plate fixation and direct CC ligament repair and 47 patient groups without direct CC ligament repair. For clinical assessments, the American Shoulder and Elbow Surgeons score, constant score, and time for implant removal were recorded. The corcoclavicular distance (CCD) and the CCD ratio were used for the evaluation of reduction. Typical reported complications, such as secondary dislocation, implant failure or loosening, peri-implant fracture, acromion osteolysis, and postoperative ACJ arthrosis, were also analyzed.

RESULTS

There were no differences in the clinical outcomes between the two groups. There was no difference in the timing of implant removal between the two groups. The last follow-up CCD was not statistically significant between group with direct CC ligament repair and without repair (9.1 ± 3.3 vs. 9.0 ± 2.8, respectively, p > 0.05). The last follow-up CCD ratio showed significant differences between the two groups (12.6 ± 25.5% vs. 26.3 ± 39.7, respectively, p < 0.05). There was no statistically significant difference in the complication rate between the two groups.

CONCLUSION

The hook plate fixation with direct CC ligament repair group was better for maintenance of reduction than that of the hook plate fixation without direct CC ligament repair group. Although, there were no differences of clinical outcomes and complications between two groups.

LEVEL OF EVIDENCE

Level III, Retrospective Study.

RR, Costa G, Verdalet I, Ezzeddine H, Rius X. Arthroscopically Assisted Comprehensive Double Cerclage Suture Fixation Technique for Acute Acromioclavicular Joint Separation

Acromioclavicular dislocations are some of the most frequently recorded and controversial injuries in the athletic population. These injuries have historically been a matter of disagreement between surgeons, particularly when it comes to the surgical technique used to treat them, its approach, or its timing. Consensus over the "gold standard" procedure to treat them is yet to be established. Even though numerous surgical techniques have already been described, the number of complications and loss of reduction remains a matter of concern for treating physicians. Here, we present an arthroscopically assisted coracoclavicular and horizontal acromioclavicular fixation technique in a modified figure-of-eight configuration using 2 strong FiberTape Cerclage sutures, with measurable tension, for the comprehensive treatment of acromioclavicular joint dislocations.

Imaging of the Acromioclavicular Joint: Anatomy, Function, Pathologic Features, and Treatment

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.

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

Background:

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

Hypothesis:

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

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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

Common Injuries of the Weekend Athlete

Each year increasing numbers of people participate in a wider variety of athletic endeavors. Unlike previous generations, many patients remain in these activities later into their lives, some well beyond retirement. As the population ages and their activities continue, they are subject to injury of various forms affecting all aspects of their bodies.

Ultrasound-guided percutaneous treatment of a calcific acromioclavicular joint: A case report

RATIONALE

Calcific tendinopathy is one of the most frequent causes of nontraumatic shoulder pain. However, intra-articular calcifications appear to be an infrequent condition. We herein report a rare case study of an intra-articular calcification of the acromioclavicular joint.

PATIENT CONCERNS

A 46-year-old man presented with an acute pain in the anterior superior region of the left shoulder which also radiated to the left cervical region. The man during the physical evaluation also presented severe functional limitation of the shoulder movements in all planes of motion.

DIAGNOSES

The diagnosis was carried out through a radiographic and an echotomographic examination, highlighting the intra-articular calcific formation associated to a reactive inflammatory reaction.

INTERVENTIONS

An ultrasound-guided percutaneous treatment following the guidelines for calcific tendinopathy of the shoulder was carried out.

OUTCOMES

The posttreatment was satisfactory with the disappearance of the pain and the recovery of the shoulder movements in all planes of motion.

LESSONS

We can affirm that the ultrasound-guided percutaneous treatment in patients with calcification of the acromion-clavicular joint represents a valid and nonpainful therapeutic treatment.

Coracoid clavicular tunnel angle is related with loss of reduction in a single-tunnel coracoclavicular fixation using a dog bone button in acute acromioclavicular joint dislocation

PURPOSE

Despite the high failure rates of techniques used to maintain the reduction of single-tunnel coracoclavicular (CC) fixation, analyses of the etiology of loss of reduction related to surgical techniques are limited. Therefore, it was hypothesized that the initial coracoclavicular tunnel angle was related to loss of reduction in the single-tunnel technique for AC joint dislocation. This study aimed to evaluate the clinical and radiological outcomes of arthroscopic single-tunnel CC suture button fixation according to the initial coracoclavicular tunnel angle.

METHODS

Thirty-two consecutive patients who underwent arthroscopic single-tunnel CC suture button fixation for AC joint dislocation from 2014 to 2018 were enrolled. The tunneling-first technique was used in the first 11 patients, while the reduction-first technique was used in the remaining 22 consecutive patients. For clinical assessments, the American Shoulder and Elbow Surgeons (ASES) score and Korean Shoulder Score (KSS) were recorded. For radiological evaluation, coracoclavicular distance ratio, coracoclavicular tunnel angle, coracoid, and clavicular tunnel widths were measured.

RESULTS

The ASES score did not differ significantly between the two groups (n.s.). However, the KSS was significantly better in the reduction-first group (p = 0.031). No significant intergroup differences were observed in the pre- and postoperative coracoclavicular distance ratio. However, at the last follow-up, loss of coracoclavicular distance ratio was significantly smaller in the reduction-first group (p < 0.001). At the final follow-up, loss of the coracoclavicular distance ratio was positively correlated with the postoperative coracoclavicular tunnel angle (p < 0.001, Spearman's rho correlation coefficient = 0.602). The final follow-up clavicular tunnel width was also significantly smaller in the reduction-first group (p = 0.002). Finally, the last follow-up clavicular tunnel width was positively correlated with the postoperative coracoclavicular tunnel angle (p = 0.008, Spearman's rho correlation coefficient = 0.459).

CONCLUSION

The reduction-first technique showed better clinical and radiological outcomes than the tunneling-first technique in single-tunnel CC fixation for AC joint dislocation. A large postoperative coracoclavicular tunnel angle was associated with loss of reduction and clavicular tunnel widening. Therefore, obtaining a straight coracoclavicular tunnel angle is crucial for achieving better outcomes and minimizing loss of reduction.

LEVEL OF EVIDENCE

III.

Clavicle and coracoid process periprosthetic fractures as late post-operative complications in arthroscopically assisted acromioclavicular joint stabilization

PURPOSE

Arthroscopic-assisted stabilization surgery for acute acromioclavicular joint (ACJ) disruption shows excellent and reliable clinical outcomes. However, characteristic complications such as fracture of the clavicle and coracoid have been reported to occur during the early post-operative period. The main goal of this study was to highlight the occurrence of fractures as a late post-operative complication. The secondary goals were to describe possible fracture morphologies and treatment outcomes.

METHOD

Patient records from a single surgery centre were searched for all patients presenting with late fracture complication following arthroscopically assisted acromioclavicular stabilization. Medical reports including the operative notes and pre- and post-operative X-rays were reviewed. A telephone interview was conducted with each patient to access the American Shoulder and Elbow Surgeons shoulder score.

RESULTS

A total of four patients presented with late fracture complication following arthroscopic-assisted ACJ stabilization surgery. All patients were males and presented following trauma at a median duration of 19.5 months after the index surgery. Fracture morphology differed between patients; the treatment was conservative in three patients, while one patient underwent osteosynthesis.

CONCLUSION

Traumatic peri-implant fractures can occur, even 2 years after arthroscopically assisted ACJ reconstruction. This needs to be considered when planning for surgical intervention in acute ACJ disruption, especially in a high-risk population.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.