Challenges in Treating Acromioclavicular Separations: Current Concepts

The Effect of Clavicular Tunnel Position on Reduction Loss in Patients with Acute Acromioclavicular Joint Dislocations Operated with a Single-Bundle Suspensory Loop Device

OBJECTIVE

The treatment of acromioclavicular joint (ACJ) dislocations offers numerous options, and ongoing debates persist regarding their comparative effectiveness. Among these options, the suspensory loop device (SLD) is one of the most favored treatment modalities. Despite the observed high reduction loss rate associated with SLD, the treatment yields favorable clinical outcomes. This study aimed to investigate the clinical outcomes of patients with acute type 3 and 5 ACJ dislocations who underwent open and arthroscopic procedures using a single-bundle SLD, and to evaluate the effect of clavicular tunnel position on reduction loss.

METHODS

Thirty-seven eligible patients diagnosed with acute type 3 and type 5 ACJ dislocation who underwent open and arthroscopic surgery with a single-bundle SLD between January 2015 and March 2022 were evaluated retrospectively. Demographic data and radiological measurements including coracoclavicular (CC) interval, clavicle length (CL), and implant distance (ID) were recorded. The ID/CL ratio was calculated and a value between 0.17 and 0.24 was considered as "acceptable implant position". Reduction loss and other complications were noted. Patients were divided into two groups: open (Group 1) and arthroscopic (Group 2). Constant Murray Score (CMS) and Visual Analog Scale (VAS) were used for clinical and functional outcomes. Non-parametric tests were used for statistical analysis of variables.

RESULTS

The study included six females (16.2%) and 31 males (83.8%) with a mean age of 40.2 ± 14.7 years (range: 20-75). The mean follow-up period was 22.3 ± 16.7 months (range: 6-72). The average time from trauma to surgery was 6.3 ± 5.3 days (range: 1-18). At the last follow-up, the CMS was 89.3 ± 8.8 and the VAS score was 2.1 ± 0.9. The mean ID/CL ratio was 0.19 ± 0.1 and 19 patients (51.4%) were between 0.17 and 0.24. Reduction loss was observed in nine patients (24.3%). There were no significant differences between Group 1 and Group 2 regarding operation time (p = 0.998), ID/CL ratio (p = 0.442), reduction loss (p = 0.458), CMS (p = 0.325), and VAS score (p = 0.699). Of the 28 patients without reduction loss, 16 had an ID/CL ratio between 0.17 and 0.24 (p = 0.43). Furthermore, within the 0.17-0.24 interval, CMS was higher with an average of 91.8 ± 5.1 compared to the other intervals (p = 0.559).

CONCLUSION

The clinical and functional outcomes of acute type 3 and type 5 ACJ dislocation operated open and arthroscopically with single-bundle SLD are similar and satisfactory. A clavicular tunnel position in the range of 0.17-0.24 (ID/CL ratio) is recommended to maintain postoperative reduction.

Current trends in surgical treatment of the acromioclavicular joint injuries in 2023: a review of the literature

Background

This article examines the wide range of surgical reconstruction options available for acromioclavicular (AC) joint injuries. However, the lack of consensus regarding the most suitable surgical techniques is attributed to the high and variable failure rates observed with current approaches.

Methods

This article presents a comprehensive overview of the current surgical principles and techniques used by renowned experts in the field of AC shoulder injury management.

Results

It emphasizes the significance of addressing horizontal and rotational instability in AC injuries and highlights the impact of impaired scapular biomechanics.

Conclusion

By exploring these emerging concepts and strategies, the article aims to lay the foundation for future studies aimed at improving treatment outcomes and patient management.

Efficacy of allogeneic tendon material coracoclavicular ligament reconstruction combined with Kirschner wire and titanium alloy hook plate material fixation in the treatment of acromioclavicular joint dislocation

Objective

To compare the effects of allogeneic tendon coracoclavicular ligament reconstruction combined with Kirschner wire fixation and clavicular hook plate fixation on early postoperative pain, postoperative shoulder joint function score and shoulder joint mobility in patients with acromioclavicular joint dislocation.

Methods

From January 2020 to January 2023, 43 patients with acromioclavicular joint dislocation admitted to Xi 'an Honghui Hospital were included. Among them, 24 patients were treated with the clavicular hook plate technique (Hook Plate,HP) group, and 19 patients were treated with allogeneic tendon coracoclavicular ligament reconstruction combined with the Kirschner wire technique (Allogeneic Tendon, AT) group. The Constant-Murley score of shoulder joint function 6 months after operation, postoperative shoulder joint activity, preoperative and postoperative pain, operation time, intraoperative blood loss and complications were compared between the two groups.

Results

All 43 patients were followed up for an average of 9.7 (9-12) months. The intraoperative blood loss in the allogeneic tendon group was less than in the hook plate group. The Constant-Murley shoulder function score was higher than that in the hook plate group 6 months after the operation. The abduction and lifting activity was greater than that in the hook plate group. The visual analogue scale scores at 3 days and 14 days after operation were lower than those in the hook plate group. The difference was statistically significant (p < 0.001). There was 1 case (5.3%) of exudation around the Kirschner needle track in the allogeneic tendon reconstruction group, and 5 cases (20.8%) of complications in the hook plate group, including 1 case of internal fixation stimulation, 2 cases of acromion impingement syndrome, 1 case of acromioclavicular joint osteoarthritis, and 1 case of shoulder joint stiffness. The complication rate of the allogeneic tendon group was lower than that of the hook plate group.

Conclusion

The clinical efficacy of allogeneic tendon coracoclavicular ligament reconstruction combined with Kirschner wire fixation in treating acromioclavicular joint dislocation (Rockwood type III-V) is better than hook plate internal fixation. The patients have less early postoperative pain and better recovery of shoulder joint function and shoulder joint mobility.

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.

Clavicular Tunnel Widening After Acromioclavicular Stabilization Shows Implant-Dependent Correlation With Postoperative Loss of Reduction

PURPOSE

To radiographically describe, quantify, and compare clavicular tunnel widening (cTW) of 2 different types of stabilization devices and investigate a possible correlation between cTW and loss of reduction.

METHODS

In a retrospective analysis of single-center registry data, we compared patients who were treated for an acute AC dislocation (Rockwood types III to V) with either the AC Dog Bone (DB) or low-profile AC (LP) repair systems. On 6-week and 6-month postoperative radiographs, we measured clavicle height and tunnel diameter. We calculated the button/clavicle filling (B/C) ratio to quantify how much of the clavicular tunnel height is covered by the low-profile inlet. The association between B/C ratio and the extent of cTW was defined, and we also compared cTW between treatment groups. Reduction of the AC joint was graded as either stable, partially dislocated or dislocated depending on the AC ratio. A 2-sample t-test was used for comparing cTW progression between the 2 groups. For continuous variables between more than 2 groups, the Kruskal-Wallis test was used.

RESULTS

Of 65 eligible patients, there were 37 and 28 included in the DB and LP groups, respectively. Overall, cTW was conically shaped with transclavicular widening noted in the DB group and cTW developing strictly inferior to the button in the LP group. For both implants, mean maximal cTW was 7.1 mm and located at the inferior cortex; the B/C ratio was not associated with increased inferior cTW (r = -0.23, P = .248). Only LP patients with complete loss of reduction had significantly increased cTW (P = .049).

CONCLUSIONS

Conical-shaped cTW is a common implant-independent phenomenon after AC stabilization using suture-button devices. It occurs only at the suture-bone interface and is less excessive for the LP implant. There is an association between increased cTW and loss of reduction specific to the LP implant only.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Acromioclavicular joint injuries at a Colorado ski resort

BACKGROUND

Acromioclavicular joint (ACJ) injuries are among the most common injuries in contact and non-contact sports. As winter sports become more popular, there has been an increase in shoulder injuries among recreational skiers and snowboarders.

METHODS

This was a retrospective analysis of all patients who presented to the Denver Health Winter Park Medical Center with ACJ injury from 2012 to 2017. We examined the incidence of ACJ injuries, the injury mechanism, demographics, and type of ACJ injuries among skiers and snowboarders treated at the clinic.

RESULTS

A total of 341 ACJ injuries (6.7% of total visits) were encountered during the study period. The majority of ACJ injures were type I (41.3%) and mainly occurred in men (86.5%). Most (96.8%) of the cases were primary ACJ injuries on the right shoulder (56.9%). The average age of patients with ACJ injuries was 30.0 years (range 10-72). More than half (62.2%) of ACJ injuries occurred while snowboarding. The most common mechanism of injury (93.5%) was fall to the snow while skiing/snowboarding. Women were more likely to have a type I ACJ injury than men (80.4% vs 35.4%; P < 0.001). Women with ACJ injuries were more likely to suffer the injury while skiing than snowboarding (71.7% vs 28.3%; P < 0.001), compared to men who were more likely to suffer the injury while snowboarding than skiing (67.5% vs 32.5%; P < 0.001).

CONCLUSIONS

Most of the ACJ injuries were type I and occurred mostly in men. Snowboarders were more likely to have an ACJ injury than skiers.

LEVEL OF EVIDENCE

Level IV, Epidemeiology Study.

Deltotrapezial Stabilization of Acromioclavicular Joint Rotational Stability: A Biomechanical Evaluation

Background

Despite advances in surgical management of acromioclavicular (AC) joint reconstruction, many patients fail to maintain sustained anatomic reduction postoperatively.

Purpose

To determine the biomechanical support of the deltoid and trapezius on AC joint stability, focusing on the rotational stability provided by the muscles to posterior and anterior clavicular rotation. A novel technique was attempted to repair the deltoid and trapezius anatomically.

Study Design

Controlled laboratory study.

Methods

Twelve human cadaveric shoulders (mean ± SD age, 60.25 ± 10.25 years) underwent servohydraulic testing. Shoulders were randomly assigned to undergo serial defects to either the deltoid or trapezius surrounding the AC joint capsule, followed by a combined deltotrapezial muscle defect. Deltotrapezial defects were repaired with an all-suture anchor using an anatomic technique. The torque (N·m) required to rotate the clavicle 20° anterior and 20° posterior was recorded for the following conditions: intact (native), deltoid defect, trapezius defect, combined deltotrapezial defect, and repair.

Results

When compared with the native condition, the deltoid defect decreased the torque required to rotate the clavicle 20° posteriorly by 7.1% (P = .206) and 20° anteriorly by 6.1% (P = .002); the trapezial defect decreased the amount of rotational torque posteriorly by 5.3% (P = .079) and anteriorly by 4.9% (P = .032); and the combined deltotrapezial defect decreased the amount of rotational torque posteriorly by 9.9% (P = .002) and anteriorly by 9.4% (P < .001). Anatomic deltotrapezial repair increased posterior rotational torque by 5.3% posteriorly as compared with the combined deltotrapezial defect (P = .001) but failed to increase anterior rotational torque (P > .999). The rotational torque of the repair was significantly lower than the native joint in the posterior (P = .017) and anterior (P < .001) directions.

Conclusion

This study demonstrated that the deltoid and trapezius play a role in clavicular rotational stabilization. The proposed anatomic repair improved posterior rotational stability but did not improve anterior rotational stability as compared with the combined deltotrapezial defect; however, neither was restored to native stability.

Clinical Relevance

Traumatic or iatrogenic damage to the deltotrapezial fascia and the inability to restore anatomic deltotrapezial attachments to the acromioclavicular joint may contribute to rotational instability. Limiting damage and improving the repair of these muscles should be a consideration during AC reconstruction.

Reliability of Upright Chest Radiography as a Diagnostic Screening Tool for Acromioclavicular Joint Dislocations

Background

The standard radiographic view for diagnosing acromioclavicular joint (ACJ) dislocations is the Zanca view of both shoulders to assess superior displacement of the distal clavicle by measuring the coracoclavicular distance (CCD) and comparing it with the uninjured shoulder; however, there is no consensus on a gold standard for diagnostic measures to classify acute ACJ injuries.

Purpose

To compare the CCD from an upright chest radiograph with a standard Zanca view of both shoulders in patients with an ACJ dislocation.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

We reviewed the records of 70 patients with an ACJ dislocation between 2010 and 2021 who had both an upright chest radiograph and a Zanca view. An ACJ dislocation was classified as low grade (Rockwood types 1-3) or high grade (Rockwood type 5). The CCD was measured on the upright chest radiograph and the Zanca view by 2 independent reviewers, and the percentage of the CCD difference compared with the unaffected side (ΔCCD) was calculated and compared between the upright chest radiograph and the Zanca view. Interrater and intrarater reliability were determined using the intraclass correlation coefficient.

Results

Included were 70 patients (55 male and 15 female; mean age, 46 years). There were 29 patients (41.43%) with a low-grade injury and 41 patients (58.57%) with a high-grade injury. In the overall analysis, the ΔCCD on the upright chest radiograph and Zanca view was significantly different (130.25% ± 88.42% vs 152.69% ± 106.56%, respectively; mean difference, 22.44% [95% CI, 2.40% to 42.48%]; P = .029). The subgroup analysis revealed that the ΔCCD on the upright chest radiograph and Zanca view was significantly different for patients with a low-grade injury (60.71% ± 25.79% vs 91.46% ± 68.54%, respectively; mean difference, 30.76% [95% CI, 7.18% to 54.33%]; P = .012) but not different for patients with a high-grade injury (179.45% ± 83.87% vs 196.00% ± 107.97%, respectively; mean difference, 16.56% [95% CI, -14.06% to 47.18%]; P = .281). The intraclass correlation coefficients for the ΔCCD measurements indicated good to excellent interrater and intrarater reliability.

Conclusion

The study findings indicated that upright chest radiography can be used as a diagnostic screening tool for high-grade ACJ dislocations, but not for low-grade ACJ injuries, compared with the Zanca view.

Biologic and synthetic ligament reconstructions achieve better functional scores compared to osteosynthesis in the treatment of acute acromioclavicular joint dislocation

PURPOSE

To systematically review the outcomes of surgical treatments of acute acromioclavicular joint dislocation.

METHODS

Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of acute acromioclavicular joint dislocations were included. Following data were extracted: authors and year, study design, level of evidence, number of patients, age, classification of acromioclavicular joint dislocation, time to surgery, surgical technique, follow-up, clinical and imaging outcomes, complications, and failures. Descriptive statistics was used, when a data pooling was not possible. Comparable outcomes were pooled to generate summary outcomes reported as frequency-weighted values. Quality appraisal was assessed through the MINORS checklist.

RESULTS

One hundred and thirty-three studies were included for a total of 4473 shoulders. Mean age of participants was 36.9 years. Mean follow-up was 42.06 months. Arthroscopy showed better ASES (p < 0.0001) and lower VAS pain score (p = 0.0249) compared to an open approach. Biologic and synthetic reconstructions demonstrated better results over osteosynthesis techniques. Biologic techniques showed overall better Constant (p = 0.0001) and DASH (p = 0.0215) scores, while synthetic reconstruction showed better UCLA score (p = 0.0001). Among suture buttons, triple button showed overall better results in Constant (p = 0.0001) and VAS (p = 0.0001) scores, while better results in DASH score (p = 0.0003) were achieved by 2 double button techniques. Overall, the level of evidence was low.

CONCLUSION

Biological and synthetic reconstructions achieved better functional scores compared to osteosynthesis. Among suture buttons, the triple button showed better functional performance.

LEVEL OF EVIDENCE

IV.

Simultaneous Clavicle Fracture and Acromioclavicular Joint Dislocation: Novel Surgical Technique: A Case Report

CASE

A 41-year-old man sustained a midshaft clavicle fracture with associated type IV ipsilateral acromioclavicular joint (ACJ) dislocation. The clavicle was fixed with a locking plate and ACJ stabilized with a novel technique: 2 metal anchors with preloaded suture fixed at the coracoid process, looping the sutures over the clavicle, and passing through the plate holes without clavicle bone drilling. Excellent functional outcomes for range of motion, pain, and functional scores persisted 2 and a half years after surgery.

CONCLUSION

The described surgical technique achieved exceptional short-term outcomes, sparing clavicle bone stock and allowing an early return to sports.

The true axial shoulder projection: Diagnostic aid for acromioclavicular joint dislocation?

INTRODUCTION

Acromioclavicular joint dislocations are common. Differentiating between horizontal and vertical instability is challenging, but possible to diagnose on axial radiographs. No clear consensus for axial radiograph parameters currently exists. We aim to establish a reproducible technique to assess whether an axial radiograph represents a true axial view of the shoulder.

METHODS

One hundred CT scans of normal uninjured shoulders were examined using multiplanar reformatting to assess the distance between the anterior glenoid (reference line) and anterior-most aspect of the acromion in the axial plane. Measurements were repeated and performed by multiple observers to give of intra- and inter-observer reliability.

RESULTS

The mean distance from the anterior acromion to the reference line was -2.6 mm (i.e. posteriorly placed) (SD = 5.8 mm, range -16.9-13.2 mm). Most (89%) of the measurements were between 9 and -9 mm to the reference line. Intra-observer reliability was high with Cronbach's α measurement as 0.997. Inter-observer reliability gave a Cronbach's α measurement of 0.959.

CONCLUSION

When the anterior aspect of the acromion lies within 10 mm either side of a line parallel to the scapula blade at the anterior aspect of the glenoid on an axial radiograph, it represents a true axial projection of the glenohumeral joint (GHJ).Level of evidence: IV, Case series.

Better Radiographic Reduction and Lower Complication Rates With Combined Coracoclavicular and Acromioclavicular Ligament Reconstruction Than With Isolated Coracoclavicular Reconstruction

PURPOSE

To determine whether combined acromioclavicular (AC) ligament reconstruction and coracoclavicular (CC) ligament reconstruction without bone tunnels would improve radiographic reduction maintenance and complication rates for type III to V AC dislocations.

METHODS

This single-institution retrospective study analyzed all patients who underwent a hybrid synthetic/graft wrap CC reconstruction without tunnels with additional AC reconstruction/repair from January 2013 to August 2019. This 26-patient cohort was compared with a 1:1 sex- and age-matched control group who underwent CC reconstruction without AC reconstruction. CC distances on postoperative radiographs were compared with normal contralateral shoulders.

RESULTS

Of the 93 patients who underwent AC reconstructive surgery during this time period, 26 patients (96% male) met the inclusion criteria. The AC/CC cohort had 23.5% type III injuries, 23.1% type IV injuries, and 53.8% type V injuries, similar to the control group. Final radiographs of the operative shoulder's CC distance were (mean ± standard deviation) 0.9 ± 4.0 mm greater than that of the contralateral shoulder (9.6 ± 8.7 mm) in the AC/CC cohort. Final radiographs of the operative shoulder's coracoclavicular distance were 4.0 ± 4.7 mm greater than that of the contralateral shoulder (13.3 ± 9.3 mm) in the CC control group, a significant difference (P = .014). The AC/CC reconstruction group had fewer patients with a loss of reduction >5 mm (11.5% versus 38.5%, P = .025). The complication rate in the CC control group was higher than in the AC/CC cohort (30.7% versus 7.7%, P = .035). The reoperation rate was also greater in the CC control group (8 versus 1, P = .010).

CONCLUSION

This cohort study shows that the addition of AC reconstruction to CC reconstruction using synthetic tapes/grafts or allograft tissues without bone tunnels significantly improves durable radiographic outcomes, diminishes complication rates, and improves reoperation rates.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Treatment of a Failed Type V Acromioclavicular Separation Due to Coracoid Fracture: Revision of Acromioclavicular-Coracoclavicular Reconstruction and Coracoid Fixation

Acromioclavicular (AC) injuries are common, especially in the young and active population. AC joint dislocations account for 8% of all joint dislocations and are even more common in contact sports. These injuries are graded as type I through type VI on the basis of the Rockwood classification method. Types I and II are generally treated without surgery whereas types IV, V, and VI are best treated operatively. Type III dislocations remain controversial in terms of treatment, and many surgeons recommend nonoperative treatment first and operative treatment in case of continued symptoms such as pain, instability, or shoulder girdle dysfunction. The goal of operative treatment is to restore AC joint stability, which involves addressing both the coracoclavicular and coracoacromial ligaments to achieve a desirable patient outcome. The objective of this Technical Note is to describe our technique for management of a failed acromioclavicular stabilization, treated with a coracoclavicular and AC joint capsular reconstruction using tibialis anterior and semitendinosus allografts.

Acromioclavicular Joint Separation: Repair Through Suture Anchors for Coracoclavicular Ligament and Nonabsorbable Suture Fixation for Acromioclavicular Joint

OBJECTIVE

To evaluate the clinical and radiographic outcomes of patients undergoing coracoclavicular (CC) ligament repair by two suture anchors and acromioclavicular (AC) joint (ACJ) fixation using heavy nonabsorbable sutures for the treatment of types III-V ACJ injuries with a minimum of 1-year follow-up.

METHODS

The clinical and radiographic outcomes of 36 consecutive patients (26 men and 10 women) who underwent anatomic reduction for acute ACJ dislocation using two suture anchors for CC ligament reconstruction and two strands of non-absorbable stitches for ACJ fixation between December 2013 and December 2018 were reviewed. Two 3.5 mm suture anchors with double-loaded sutures were separately inserted into the anterolateral and posteromedial portions of the coracoid process. The suture strands were passed through the hole created in the clavicle using 2.0 mm drill and tied over the clavicle. Additional ACJ augmentation using two strands of non-absorbable heavy sutures was performed in all patients. At 3, 6, and 12 months and last follow-up visit, the scores on the visual analog scale (VAS), the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, and simple shoulder test (SST) questionnaires were used to provide a final evaluation of shoulder function. Comparison between baseline and treatment results was performed. Radiographic analysis included vertical displacement and horizontal shift.

RESULTS

A total of 29 patients (20 men and nine women) were included in the study. A total of seven, six, and 16 patients had Rockwood type III, type IV, and type V ACJ dislocations, respectively. The mean patient age was 42.8 ± 13.5 years, with a mean follow-up of 28 months (range, 12-56 months). At the 12-month follow-up, the mean ASES score was 92.1 ± 3.5, with a mean pain score of 0.5 ± 0.7 on the VAS and mean Constant-Murley score of 93.0 ± 2.4. The new number of positive answers on the SST was 11.5 ± 0.6. Compared with the baseline, the clinical results improved significantly (P < 0.05). No significant difference could be found between the 6- and 12-month follow-up evaluations (P > 0.05). Radiographs showed two partial loss of reduction, whereas no horizontal displacement was found in all patients. One patient developed a superficial wound infection 3 weeks postoperation. The wound healed after routine wound care. No neurovascular complications were recorded.

CONCLUSIONS

CC ligament reconstruction using two suture anchors and ACJ augmentation using two strands of non-absorbable heavy sutures on high-grade AC dislocation is a reliable technique for restoring stability to the ACJ and can obtain good to excellent clinical results.

Surgical techniques for management of acromioclavicular joint separations: review and update for radiologists

Imaging plays a central role in the postoperative management of acromioclavicular (AC) joint separations. There are more than 150 described techniques for the surgical management of AC joint injuries. These procedures can be categorized as varying combinations of the following basic techniques: a) soft-tissue repair, b) trans-articular AC joint fixation, c) coracoclavicular (CC) fixation, d) non-anatomic reconstruction of the CC ligaments, e) anatomic reconstruction of the CC ligaments, f) distal clavicle resection, and g) dynamic muscle transfer. The goals of this article are to describe the basic techniques for the surgical management of AC joint separations with an emphasis on technique-specific complications and postoperative imaging assessment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison between Trans-articular and Subacromial Stabilization with Ligament Repair for Acute Acromioclavicular Dislocation

Background:

Although numerous treatment options for acromioclavicular joint dislocation have been reported, the treatment strategy is not yet standardized.

Objective:

The purpose of this study was to evaluate the clinical and radiographic results of coracoclavicular ligament repair with temporary acromioclavicular stabilization using suture anchors and Kirschner wires, and to compare the results between temporary trans-articular fixation and subacromial stabilization of the acromioclavicular joint.

Methods:

Thirty-three cases with displaced acromioclavicular joint dislocation were retrospectively evaluated. In the first 14 cases, the wires temporarily penetrated the joint for an average of 7 weeks (trans-articular group), while the acromioclavicular joint was temporarily stabilized by wires passing under the acromion that were inserted into the distal clavicle for an average of 13 weeks in the latter 19 cases (subacromial group). Clinical and radiographic results were evaluated and compared between the two groups.

Results:

The average UCLA score was 32.0 points in the trans-articular group and 32.8 points in the subacromial group, indicating no difference between the two groups (P = 0.418). Coracoclavicular distance ratio after surgery was significantly smaller in the subacromial group (P ≤ 0.035), and acromioclavicular dislocation ratio after removal of the wires was also smaller in the subacromial group (P ≤ 0.001) compared with the trans-articular group.

Conclusion:

This study revealed that coracoclavicular ligament repair with temporary acromioclavicular stabilization leads to favorable clinical results, with the subacromial group showing better maintenance of joint reduction compared with the trans-articular group. Subacromial wire stabilization is a viable option for long-term temporary fixation of acute displaced acromioclavicular joint dislocation.

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.

Anatomic Acromioclavicular Ligament Reconstruction Using Semitendinosus Autograft With Suture Augmentation: Surgical Technique

Acromioclavicular (AC) joint separations are common injuries and account for 3.2% of shoulder injuries. These injuries typically occur among adolescent and young adult athletes during contact sports, such as hockey, wrestling, and rugby. Low-grade AC joint separations (Rockwood grade I-II) are often successfully treated nonoperatively. High-grade AC joint separations (Rockwood grade IV-VI) have the potential to alter scapular kinematics, causing painful and restricted motion, and are often treated surgically. Over 150 surgical techniques have been described to treat AC joint separations. Techniques vary in the types of implants used (screws, pins), use of anatomic or nonanatomic reconstructions, number of drill holes used, use of arthroscopic or open procedures, use of distal clavicle resection, and types of augmentation (allografts, autografts, sutures). The procedure can be expensive, with the implants and grafts costing varied amounts and, at times, thousands of dollars. The purpose of this Technical Note is to describe an inexpensive method of open anatomic AC joint reconstruction using a single bone tunnel, suture tape, and a semitendinosus autograft.