Reconstruction of Coracoclavicular Ligaments with Semitendinosus Autograft and Temporary Kirschner Wires is a good option for Chronic Acromioclavicular Joint Instability

Introduction

This study reports the results of surgical anatomic reconstruction of torn coracoclavicular ligaments with an autogenous semitendinosus graft and temporary Kirschner wires (K-wires) in chronic acromioclavicular (AC) joint dislocations.

Materials and methods

Nineteen shoulders underwent surgical anatomic reconstruction of torn coracoclavicular (CC) ligaments with an autogenous semitendinosus tendon graft and temporary K-wires for Rockwood grade III, IV and V chronic AC joint dislocations. Pre-operative data included patients' demographic characteristics, injury characteristics and surgical histories. The primary outcome measures were the University of California Los Angeles (UCLA) shoulder rating scale and visual analogue pain scoring (VAS), and the complications were noted for each patient.

Results

Surgical anatomic reconstruction of torn CC ligaments was performed in 19 patients with a mean age of 41.6±16 years (range 21-72 years). All of the patients were satisfied and felt better after CC ligament reconstruction. The average UCLA shoulder rating scale score was good/excellent: 29.4 (range 23-34) out of 35 points. The average pre-operative VAS score was 7.7 points out of 10 and improved to 1.1 points post-operatively (p<0.05). None of the patients experienced failure during the follow-up. One patient had a mild subluxation, but the patient was satisfied with the result.

Conclusions

This technique is simple, reliable, and biologic without major complications. It is also a cost-effective procedure since it can be performed with Kirschner wires and autogenous grafts. It has a major advantage of leaving no implants inside the joint, which can lead to hardware complications, and it can be performed in basic operating room settings.

Clavicular tunnel widening after coracoclavicular stabilization surgery: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to (1) estimate the prevalence of clavicular tunnel widening (TW) after coracoclavicular stabilization surgery and its risk factors and (2) assess whether TW is correlated with clavicle fracture or loss of reduction of the acromioclavicular joint (ACJ).

METHODS

In January 2023, 3 electronic databases were searched to collect data on postoperative clavicular TW, its prevalence, magnitude, and correlation with fracture and ACJ loss of reduction. Studies were classified according to the time of surgical intervention, and the clavicular tunnels were categorized by their anatomic location. Mean differences were calculated using a DerSimonian-Laird random-effects model, while binomial outcomes were pooled using the Freeman-Tukey double arcsine transformation. Univariate and multivariate meta-regression analyses were performed to determine the effect of several variables on the proportion of cases with TW.

RESULTS

Fifteen studies (418 shoulders) were included. At the final follow-up, evidence of clavicular TW was found in 70% (95% confidence interval [CI]: 70%-87%; I2 = 89%) of 221 shoulders. Surgeries in acute cases had a lower prevalence of TW (52%) compared to chronic cases (71%) (P < .001). Significant TW was found in the central tunnel (3.2 mm; 95% CI: 1.8-4.6 mm; P < .001; I2 = 72%) for acute injuries and in the medial (1.2 mm; 95% CI: 0.7-1.7 mm; P < .001; I2 = 77%) and lateral (1.5 mm; 95% CI: 0.7-2.3 mm; P < .001; I2 = 77%) tunnels for chronic cases. Single central-tunnel techniques were positively associated with the prevalence of TW (P = .046), while biotenodesis screw fixation was associated with a lower prevalence (P = .004) in chronic cases. Reconstruction of the ACJ ligament complex with tendon grafts or sutures was associated with a higher prevalence of TW (P < .001). Drill sizes between 2.5 and 5 mm were significantly associated with a lower prevalence of TW, regardless of injury chronicity (P = .012). No correlation was found between TW and the loss of ACJ reduction or clavicle fractures.

CONCLUSIONS

This systematic review and meta-analysis explored TW occurrence following coracoclavicular stabilization surgery. TW was observed in 70% of patients at final follow-up, with a higher prevalence in chronic than in acute cases. Modifiable surgical variables, such as single-tunnel tendon graft constructs for acute or chronic injuries and knotted graft procedures for chronic injuries, were significantly associated with TW. Furthermore, the prevalence of TW increased with concomitant surgical treatment of the ACJ ligament complex, and decreased with drill sizes between 2.5 and 5 mm, regardless of lesion chronicity. These surgical variables should be considered when establishing transosseous tunnels for coracoclavicular stabilization. Clavicle fractures and TW mechanisms require further investigation.

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 dislocation Rockwood type III and V show no difference in functional outcome and 91% recovered well without the need for surgery

PURPOSE

Acromioclavicular (AC) joint dislocations are common injuries, but the indication for and timing of surgery is debated. The objective of the study was to evaluate the results after acute AC joint dislocations Rockwood type III and V treated nonsurgically with the option of delayed surgical intervention.

METHODS

This is a prospective cohort study with clinical, radiological and patient-reported outcome assessment at baseline, 6 weeks, 3 months, 6 months and 1 year after acute AC joint dislocation. Patients aged 18-60 with acute AC joint dislocation and a baseline panorama (Zanca) radiograph with an increase in the coracoclavicular distance of >25% compared to the uninjured side were eligible for inclusion. All patients were treated nonsurgically with 3 months of home-based training and with the option of delayed surgical intervention. The primary outcome was the Western Ontario Shoulder Instability Index (WOSI). Secondary outcomes were surgery yes/no and the Shoulder Pain and Disability Index (SPADI).

RESULTS

Ninety-five patients were included. Fifty-seven patients were Rockwood type III and 38 patients were type V. There were no statistically significant differences in WOSI and SPADI between patients with type III and V injuries at any time point. Nine patients (9.5%) were referred for surgery; seven type III and two type V (ns).

CONCLUSION

Ninety-one percent of patients with acute AC joint dislocation Rockwood type III and V recovered without surgery and there were no differences in outcome scores between type III and V at any time point.

LEVEL OF EVIDENCE

Level IV.

[Open reduction and internal fixation in treatment of four cases of bipolar clavicle dislocations]

Objective

To summarize the method and effectiveness of open reduction and internal fixation in the treatment of 4 cases of bipolar clavicle dislocations.

Methods

Between June 2017 and June 2022, 4 patients with bipolar clavicle dislocations were admitted. There were 3 males and 1 female. The age ranged from 27 to 63 years, with an average age of 45 years. There were 2 cases of crushing injury of mine car, 1 case of traffic accident injury, and 1 case of heavy object injury. The time from injury to operation was 3-7 days, with an average of 5.0 days. The sternoclavicular joint dislocations were classified as Grade Ⅱ in 1 case and type Ⅲ in 3 cases, and anterior dislocation in 3 cases and posterior dislocation in 1 case. The acromioclavicular joint dislocations were classified as Tossy type Ⅱ in 2 cases and type Ⅲ in 2 cases. After open reduction, the sternoclavicular joint and acromioclavicular joint were fixed with lateral malleolus locking titanium plate and clavicular hook plate, respectively.

Results

All operations were successfully completed without vascular or nerve injury. All incisions healed by first intention. All patients were followed up 12-18 months, with an average of 14 months. At last follow-up, the shoulder joint functions were rated as excellent in 3 cases and good in 1 case according to Rockwood score. During follow-up, there was no loosening of internal fixator or fracture. The internal fixators were removed in all patients at 5-7 months after operation (mean, 6 months), and no re-dislocation occurred after removal.

Conclusion

For bipolar clavicle dislocation, open reduction combined with lateral malleolus locking titanium plate fixation of the sternoclavicular joint and clavicle hook plate fixation of the acromioclavicular joint can achieve good effectiveness. It has the advantages of simple operation, high safety, firm fixation, and fewer complications, and the shoulder function recovers well.

In Vivo Analysis of Acromioclavicular Kinematics and Distance During Multiplanar Humeral Elevation

BACKGROUND

Knowledge of acromioclavicular (AC) joint kinematics and distance may provide insight into the biomechanical function and development of new treatment methods. However, accurate data on in vivo AC kinematics and distance between the clavicle and acromion remain unknown.

PURPOSE/HYPOTHESIS

The purpose of this study was to investigate 3-dimensional AC kinematics and distance during arm elevation in abduction, scaption, and forward flexion in a healthy population. It was hypothesized that AC kinematics and distance would vary with the elevation angle and plane of the arm.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 19 shoulders of healthy participants were enrolled. AC kinematics and distance were investigated with a combined dual fluoroscopic imaging system and computed tomography. Rotation and translation of the AC joint were calculated. The AC distance was measured as the minimum distance between the medial border of the acromion and the articular surface of the distal clavicle (ASDC). The minimum distance point (MDP) ratio was defined as the length between the MDP and the posterior edge of the ASDC divided by the anterior-posterior length of the ASDC. AC kinematics and distance between different elevation planes and angles were compared.

RESULTS

Progressive internal rotation, upward rotation, and posterior tilt of the AC joint were observed in all elevation planes. The scapula rotated more upward relative to the clavicle in abduction than in scaption (P = .002) and flexion (P = .005). The arm elevation angle significantly affected translation of the AC joint. The acromion translated more laterally and more posteriorly in scaption than in abduction (P < .001). The AC distance decreased from the initial position to 75° in all planes and was significantly greater in flexion (P < .001). The MDP ratio significantly increased with the elevation angle (P < .001).

CONCLUSION

Progressive rotation and significant translation of the AC joint were observed in different elevation planes. The AC distance decreased with the elevation angle from the initial position to 75°. The minimum distance between the ASDC and the medial border of the acromion moved anteriorly as the shoulder elevation angle increased.

CLINICAL RELEVANCE

These results could serve as benchmark data for future studies aiming to improve the surgical treatment of AC joint abnormalities to restore optimal function.

Long-Term Functional Outcomes and Athletic Ability in Shoulder Sports After Anatomic Coracoclavicular Ligament Reconstruction for Chronic Type 3 and 5 Acromioclavicular Joint Injuries

Background

Promising short- and midterm outcomes have been seen after anatomic coracoclavicular ligament reconstruction (ACCR) for chronic acromioclavicular joint (ACJ) injuries.

Purpose/Hypothesis

To evaluate long-term outcomes and shoulder-related athletic ability in patients after ACCR for chronic type 3 and 5 ACJ injuries. It was hypothesized that these patients would maintain significant functional improvement and sufficient shoulder-sport ability at a long-term follow-up.

Study Design

Case series; Level of evidence, 4.

Methods

Included were 19 patients (mean age, 45.9 ± 11.2 years) who underwent ACCR for type 3 or 5 ACJ injuries between January 2003 and August 2014. Functional outcome measures included the American Shoulder and Elbow Surgeons (ASES), Rowe, Constant-Murley, Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores as well as the visual analog scale (VAS) for pain, which were collected preoperatively and at the final follow-up. Postoperative shoulder-dependent athletic ability was assessed using the Athletic Shoulder Outcome Scoring System (ASOSS). Shoulder activity level was evaluated using the Shoulder Activity Scale (SAS), while the Subjective Patient Outcome for Return to Sports (SPORTS) score was collected to assess the patients' ability to return to their preinjury sporting activity.

Results

The mean follow-up time was 10.1 ± 3.8 years (range, 6.1-18.8 years). Patients achieved significant pre- to postoperative improvements on the ASES (from 54.2 ± 22.6 to 83.5 ± 23.1), Rowe (from 66.6 ± 18.1 to 85.3 ± 19), Constant-Murley (from 64.6 ± 20.9 to 80.2 ± 22.7), SST (from 7.2 ± 3.4 to 10.5 ± 2.7), SANE (from 30.1 ± 23.2 to 83.6 ± 26.3), and VAS pain scores (from 4.7 ± 2.7 to 1.8 ± 2.8) (P < .001 for all), with no significant differences between type 3 and 5 injuries. At the final follow-up, patients achieved an ASOSS of 80.6 ± 32, SAS level of 11.6 ± 5.1, and SPORTS score of 7.3 ± 4.1, with no significant differences between type 3 and 5 injuries. Four patients (21.1%) had postoperative complications.

Conclusion

Patients undergoing ACCR using free tendon allografts for chronic type 3 and 5 ACJ injuries maintained significant improvements in functional outcomes at the long-term follow-up and achieved favorable postoperative shoulder-sport ability, activity, and return to preinjury sports participation.

Acute calcific periarthritis of acromioclavicular joint: A case report

Key Clinical Message

It is of utmost importance to be aware of acute calcific periarthritis, as it may confuse the clinicians leading to misdiagnosis. Furthermore, patients may be subjected to various diagnostic and invasive procedures due to a lack of familiarity with this condition.

Abstract

Deposition of hydroxyapatite crystals in the para-articular soft tissues is a well-known condition, often involving the shoulder joint. However, the deposition of calcium salts in the para-articular soft tissue of acromioclavicular joint has rarely been described. We report a case of a 55-year-old otherwise healthy man, presented with acute onset of pain and restriction of movement of left shoulder, who was diagnosed based on radiographic findings with calcific periarthritis of the acromioclavicular joint. As suggested by the literatures, he was managed conservatively, and no reoccurrence was reported after the episode.

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.

A prospective multi-centre observational cohort study to evaluate frequency, management and outcomes of acute severe (grade III-VI) acromioclavicular joint injuries in the United Kingdom

To collect data on current management and outcome of acute severe acromioclavicular joint (ACJ) injuries to inform the knowledge base, design and conduct of future research and explore the patient and injury features predicting surgical management. A prospective cohort study was conducted by two trainee collaboratives of acute Grade III to VI ACJ injuries presenting to 12 hospital trusts. 54 Patients were recruited within four weeks of injury regardless of treatment type over a one-year period. Patient reported outcomes and healthcare resource use were collected at six and 12 months post injury. Accounting for Rockwood grade, age, gender and dominant arm injury, the operative group had a statistically lower Oxford Shoulder Score (OSS) at baseline (10.8 vs 25.3, <0.0001) and at six months (37 vs 43.8, p = 0.024) than the non-operative group. There was no statistical difference at 12 months (40 vs 44, p = 0.205). The odds of operative management were inversely correlated with baseline OSS (OR 0.89, p = 0.014). There was no clear preferential method of fixation in the ten patients that received surgery. Future research needs to take into consideration the transitory population of working age, on response to follow up. A future randomised clinical trial (RCT) should be multicentred, pragmatic and stratified for baseline function and injury grade at randomisation.

A review of the coracoclavicular joint: Description, etiology, and clinical significance

The coracoclavicular joint (CCJ) is a synovial joint that forms between the conoid tubercle of the clavicle and the coracoid process of the scapula in approximately 2.5% of the population. The number of bilateral to unilateral cases is almost equal. The number of right-sided and left-sided cases is also almost equal. It is found in both males and females but most often in male adults. Very few cases have been identified in juveniles. Found in populations all over the world, the highest frequencies of CCJ are in Asia. The etiology is unknown but it is most likely caused by metaplastic change of the trapezoid and surrounding tissue due to compression and friction of the coracoacromial ligament between the clavicle and coracoid process. Typically asymptomatic, but if so, the most common complaint is anterior should pain exacerbated by extreme abduction. Successful treatment includes steroid injection and surgical excision.

Long-term Clinical Outcomes After TightRope Versus Hook Plate Fixation for Acute Acromioclavicular Joint Dislocation

Background

There is limited information regarding the long-term efficacy of techniques for surgical fixation after acromioclavicular (AC) joint dislocation.

Purpose

To evaluate the efficacy of hook plate (HP) and TightRope (TR) fixation for acute AC joint dislocations by comparing the long-term clinical and radiological patient outcomes.

Study Design

Cohort study, Level of evidence, 3.

Methods

This study retrospectively analyzed data from 61 patients with acute AC joint dislocation between July 2011 and November 2015. The patients were grouped according to surgical procedure: HP (n = 36) and TR (n = 25). Clinical outcomes at final follow-up were evaluated using the visual analog scale (VAS) for pain; the American Shoulder and Elbow Surgery score; the Korean Shoulder Score; and the University of California, Los Angeles (UCLA) shoulder score. Side-to-side coracoclavicular (CC) distance on radiographs, postoperative complications, and the rate of subacromial erosion in the HP group were also assessed between procedures.

Results

The mean follow-up period was 7.0 ± 1.0 years, and there were no significant differences in pain or outcome scores between the HP and TR groups (all P > .05). Forward flexion was better in the TR group (172.6° ± 5.6°) versus the HP group (166.0° ± 10.8°; P = .002). The percentages of patients with a difference in the side-to-side CC distance of <5 mm were 83.3% and 72.0% in the HP and TR groups, respectively (P = .288). Complications were found in 2 patients in the HP group and 1 in the TR group (P ≥ .999). Subacromial erosion was observed in 41.7% of patients after HP fixation, with no difference in VAS pain scores at the final follow-up in patients with versus without subacromial erosion (P = .719).

Conclusion

When comparing HP with TR fixation for the treatment of acute AC joint dislocations, there were no significant differences in functional outcome scores, final CC distance, or complications. Slightly better forward flexion was seen after TR fixation. Subacromial erosion occurred in 40% of patients after HP fixation, but this did not affect long-term VAS pain scores. Both surgical techniques are effective treatment options for AC joint dislocation.

Outcomes of Secondary Arthroscopic Distal Clavicle Resection for Shoulders With Symptomatic Acromioclavicular Joint Arthropathy After Isolated Rotator Cuff Repair With Complete Tendon Healing

Background

Recent meta-analyses have advised against distal clavicle resection (DCR) as an adjuvant procedure during rotator cuff repair (RCR), whether performed routinely or in shoulders diagnosed with symptomatic acromioclavicular joint (ACJ) arthropathy. However, the efficacy of DCR as a secondary procedure in patients with persistent pain attributed to symptomatic ACJ arthropathy remains unknown.

Purpose

To evaluate outcomes of secondary DCR in patients with failed nonoperative treatment of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing.

Study Design

Case series; Level of evidence, 4.

Methods

Between 2008 and 2018, the senior surgeon performed isolated RCR in 1935 patients, of which 23 (1.2%) presented with ACJ pain and discomfort at ≥12 months after the index RCR, despite complete healing of repaired tendons. Those 23 patients underwent secondary DCR, as ACJ arthropathy was confirmed clinically and radiographically. Clinical assessment before DCR included the Subjective Shoulder Value (SSV) and pain at rest. Clinical assessment at >12 months after DCR included the SSV, pain at rest, Constant-Murley score, range of motion, and satisfaction. Pre- and post-DCR SSV and pain scores were compared.

Results

Of the initial cohort, 5 patients did not consent to the use of their data, leaving 18 patients aged 53.3 ± 7.6 years (mean ± SD; range, 39-68 years) for outcome assessment. At a mean follow-up of 7.0 ± 3.1 years after DCR, the SSV significantly improved from 58.7 ± 17.2 to 76.1 ± 20.2 (P < .001), and the pain at rest significantly decreased from 4.7 ± 1.5 to 2.8 ± 1.9 (P < .001). At final follow-up, the Constant-Murley score was 70.2 ± 21.0. Of 18 patients, 15 had none or mild residual pain (0-2; 83%), while 3 had substantial residual pain (5 or 6; 17%). Only 1 of the 3 patients with substantial residual pain had a poor SSV score (20 points) and was against opting for DCR in retrospect. No patient had infections or gross ACJ instability after DCR.

Conclusion

Secondary DCR for cases of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing reduced pain in 83% of patients, and 94% were satisfied and would undergo secondary DCR again.

Anatomic Acromioclavicular Joint Reconstruction with and without Acromioclavicular Ligament Reconstruction: A Comparative Biomechanical Study

Background

The purpose of this study was to determine if adding a reconstructed superior acromioclavicular (AC) joint ligament adds significant biomechanical stability to the AC joint over anatomic coracoclavicular (CC) ligament reconstruction alone.

Methods

Fourteen cadaver shoulders were used for the comparison of biomechanical stability among the anatomic CC ligament reconstruction alone, CC and AC ligament reconstruction, and the intact groups by measuring the displacement under cyclic loads. A load to failure test was then performed in the vertical direction at a loading rate of 2 mm /sec to determine surgical-repair joints' tolerance to the maximum failure load.

Results

The average peak-to-peak displacement induced by cyclic load in the sagittal axis and vertical axis direction was not significantly different between CC ligament reconstruction, CC and AC ligament reconstruction, and intact groups. The maximum failure load for the CC reconstruction (224.9 ± 91.8 N (Mean ± SEM)) was lower than CC/AC reconstruction groups (326.2 ± 123.3 N). The CC/AC reconstruction group failed at a significantly higher load (t test, p = 0.016) than the CC reconstruction group.

Conclusion

CC/AC reconstruction surgical technique yielded a better shoulder stability than CC ligament alone reconstruction that may better maintain reduction of the AC joint.Level of Evidence: Level II.

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.

Radiographic and anatomic variations on postoperative acromion fractures after inlay and lateralized reverse shoulder arthroplasty

INTRODUCTION

Postoperative fracture of the acromion is a complication uniquely more common after reverse shoulder arthroplasty (RSA) than other forms of shoulder arthroplasty. There is limited knowledge regarding the etiology of these fractures or the anatomic risk factors. The purpose of this study is to identify associations of the acromioclavicular (AC) joint and relative humeral and glenoid positioning on the occurrence of acromial fractures after RSA.

METHODS

A retrospective case-controlled study was performed on primary RSA patients treated by a single surgeon from September 2009 to September 2019. Patients with a postoperative acromion fracture were matched in a 3:1 ratio based on gender, indication, and age to those without a fracture and with a 2-year minimum follow-up. Preoperative and the immediate postoperative radiographs were reviewed by 2 investigators to measure critical shoulder angle, acromion-humeral interval, global lateralization, delta angle, preoperative glenoid height, and the level of inlay or onlay of the humeral stem. The morphology, width, and stigmata of osteoarthritis in the AC joint were assessed using computed tomography scans taken preoperatively.

RESULTS

Of a total of 920 RSAs performed, 47 (5.1%) patients suffered a postoperative acromion fracture. These patients were compared with a control group of 141 patients, with a mean age of 76.4 years and similar distributions of gender and surgical indication. Patients in both groups had similar preoperative glenoid height (P = .953) and postoperative degree of inset or offset of humeral implant relative to the anatomic neck (P = .413). There were no differences in critical shoulder angle, acromion-humeral interval, global lateralization, and delta angle both preoperatively and postoperatively between the fracture and nonfracture groups. Computed tomography analysis also showed no differences in AC joint morphology (P = .760), joint space (P = .124), and stigma of osteoarthritis (P = .161).

CONCLUSION

There was no relation between the features of the AC joint and the anatomic parameters of the humerus relative to the glenoid and acromion on postoperative acromion fractures after RSA.

Bifocal Stabilisation of Acute Acromioclavicular Joint Dislocation using Suture Anchor and Temporary K-Wires: A Retrospective Analysis

Introduction

The acromioclavicular joint (ACJ) is a major link connecting the upper limb to the torso. The acromioclavicular and coracoclavicular (CC) ligaments help in stabilising the joint. We feel it is prudent to address both these ligament injuries, to achieve optimum result. This study was undertaken to analyse the results of a simple frugal surgical technique we used to deal with this injury considering stabilisation for both these ligaments.

Materials and methods

In this retrospective study, skeletally mature patients with Type III, IV or V ACJ dislocations who underwent open reduction and stabilisation of the joint with temporary K-wires, repair of the capsule and augmentation of CC ligaments with suture anchors were included. Clinico-radiological and functional outcome was evaluated. Functional assessment of the upper limb was analysed using the Disabilities of Arm, Shoulder, and Hand Score (DASH), Constant shoulder score (CSS) and Oxford shoulder score (OSS).

Results

Clinical and radiological evaluation of the 32 patients who had completed two years from the index surgery, was done. Out of the 37 patients included initially, five were lost in follow-up. Majority of the subjects included were males and type V was the most common injury. Mean pre-operative CC distance on the affected side was 13.92±4.94mm. In the immediate post-operative radiograph, it was 7.63±2.08mm and in the final follow- up was 9.36±2.75mm. Measurements were taken by two independent investigators and inter, and intra-observer reliability were analysed by Interclass correlation coefficient. Excellent functional outcome was noted despite the 1.81±1.50mm average loss of correction. At final follow-up, mean DASH score was 4.67±4.18, Oxford shoulder score was 44.06±2.44 and Constant shoulder score was 86.37±5.81. The severity of the injury had no significant effect on the functional outcome post our method of stabilisation and rehabilitation.

Conclusion

Bifocal fixation restores the multidirectional stability of the disrupted ACJ. Adequate radiological reduction, good functional outcome and simplicity of execution make this technique an undemanding one for use in regular practice.

Comparing the Anatomical Landmarks Versus the Coracoid-Based Landmarks Techniques for Coracoclavicular Stabilization After High-Grade Acromioclavicular Injury: A Biomechanical Study

BACKGROUND

In acute high-grade acromioclavicular (AC) joint injuries, the aim of treatment is robust reduction and stabilization of the joint. The anatomical landmarks method is most commonly used for stabilization, but loss of reduction often occurs because of the suture tunnels.

PURPOSE/HYPOTHESIS

The purpose was to evaluate and compare the stability of coracoclavicular (CC) stabilization using the anatomical landmarks and coracoid-based landmarks techniques in treating a high-grade AC joint injury. It was hypothesized that stabilization using coracoid-based landmarks would provide better stability.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty fresh-frozen cadaveric shoulders (8 male and 2 female pairs) were randomized into 2 operative technique groups: 10 shoulders in the anatomical landmarks group and 10 shoulders in the coracoid-based landmarks group. The CC ligaments and AC capsule were cut at the midlevel, and CC stabilization and AC capsule repair were performed. For the anatomical landmarks technique, two 2.5-mm clavicular tunnels were created at 25 and 45 mm from the AC joint, while for the coracoid-based landmarks technique, two 2.5-mm clavicular tunnels were drilled using the medial and lateral borders of the coracoid base to choose the tunnel sites. Before injury creation and after stabilization, each shoulder underwent a loading force of 70 N in the superior and anteroposterior directions, and the displacement distance and stiffness were compared between the 2 techniques using the paired t test.

RESULTS

The mean difference in displacement before and after stabilization was higher in the anatomical landmarks technique than the coracoid-based landmarks technique (1.82 ± 3.52 vs -0.18 ± 4.78 mm in the superior direction and 7.47 ± 9.35 vs 1.76 ± 3.91 mm in the anteroposterior direction), but none of the differences in displacement or stiffness were statistically significant between the groups.

CONCLUSION

No significant biomechanical differences in displacement or stiffness were seen between the anatomical landmarks technique and the coracoid-based landmarks technique.

CLINICAL RELEVANCE

Either stabilization technique can be utilized for repair of the CC ligaments in an acute AC injury setting.

The correlation between acromial osteolysis and acromion types in the treatment of acromioclavicular joint dislocation with hook plate

This study aimed to radiologically evaluate the effect of hook plates used in the treatment of acromioclavicular joint (ACJ) dislocations on the development of subacromial osteolysis (SAO) according to acromion types. A total of 43 patients with mean age of 38.5 (19-77) years who were diagnosed with AC dislocation and applied neutral clavicular hook plate between 2013 and 2020 were retrospectively evaluated. Acromion types were determined by measuring acromion slope angle on lateral shoulder radiography and 3-dimensional (D)-CT of the patients. Presence of SAO was classified according to the severity of erosion in the subacromial region (grade I: minimal osteolysis, grade II: subacromial erosion <2 mm, grade III: subacromial erosion >2 mm, grade IV: cut-through of the acromion) on postoperative 3D - CT and correlation with acromion types was analyzed. Incidence of SAO was significantly higher among type 1 acromion compared to type 2 and type 3 acromion (P = .003). While osteolysis was observed in 21 patients, no osteolysis was observed in 22 patients. Osteolysis occurred in all patients with type 1 acromion, 7 patients with type 2 acromion, and 5 patients with type 3 acromion. Since the hook tip in the sagittal plane passes posterior to the center of the acromion and the concavity of the subacromial surface is inadequate in the type 1 acromion, we believe that the increased pressure applied by the hook tip on the subacromial cartilage increases the risk of SAO. We predict that the use of hook plates with an angle of 15-20 degrees, similar to the patient's AC angle, rather than neutral hook plate, will reduce the risk of osteolysis in patients with type 1 acromion.

An Accuracy Comparison of Minimally Invasive Transclavicular-Transcortical Drilling with Free-Hand, C-Shape and Assembly-Type Guide Device: An In Vitro Study

OBJECTIVES

Ensuring the accuracy of transclavicular-transcoracoid drilling in the anatomical reconstruction of the coracoclavicular ligament complex with minimally invasive incisions remains a major problem for inexperienced surgeons. The purpose of this study was to design an assembly guide device for transclavicular-transcoracoid drilling with minimally invasive incisions, to manufacture the finished product, and to compare its feasibility and accuracy with the existing C-shape guide devices and free-hand techniques.

METHODS

An assembly-type guide device was designed and produced using computer-aided design and three-dimensional printing. The specimen data of 54 human shoulders from 27 gross specimen (14 males and 13 females) treated by free-hand drilling, C-shape device drilling, and assembly-type guide device drilling from October 2018 to January 2021 were analyzed in a controlled laboratory study. Fifty-four human shoulder specimens were randomly assigned into free-hand (n = 18), C-shape (n = 18), and assembly (n = 18) groups by drawing lots for transclavicular-transcoracoid drilling by three inexperienced surgeons. After the drilling procedure was completed and the devices were removed, the operation outcomes were assessed and evaluated. Distances from the tunnel edge to the coracoid's medial (d_m ) and lateral (d_l ) edges, operation time, and tunnel location zones on the coracoid's inferior surface of all specimens in the three groups were measured to evaluate the surgical accuracy and efficiency.

RESULTS

All specimens in the three groups completed the drilling operation successfully and were correctly measured. The distance differences (d_d ) between d_m and d_l in the free-hand, C-shape, and assembly groups were 3.2 ± 1.8 mm, 1.8 ± 1.0 mm, 1.0 ± 0.8 mm, respectively. The d_d of the free-hand group was higher than that of the other two groups (p < 0.001). The tunnel exit points on the inferior coracoid surface located in undesired zones were six (33%), one (6%), and zero in the free-hand group, C-shape group, and assembly-type group, respectively (p = 0.012). The operation time in the free-hand, C-shape, and assembly groups were 198 ± 36 s, 256 ± 64 s, and 353 ± 88 s, respectively. The operation time of each group significantly differed from that of the others (p < 0.001).

CONCLUSION

The assembly-type devices may be the first choice for inexperienced surgeons while both the C shape devices and assembly-type guide devices achieved higher accuracy than free-hand techniques.

The Role of the Trapezius in Stabilization of the Acromioclavicular Joint: A Biomechanical Evaluation

Background

Acromioclavicular joint (ACJ) injuries are common, and many are adequately treated nonoperatively. Biomechanical studies have mainly focused on static ligamentous stabilizers. Few studies have quantified ACJ stabilization provided by the trapezius.

Purpose/Hypothesis

To elucidate the stabilization provided by the trapezius to the ACJ during scapular internal and external rotation (protraction and retraction). It was hypothesized that sequential trapezial resection would result in increasing ACJ instability.

Study Design

Controlled laboratory study.

Methods

A biomechanical approach was pursued, with 10 cadaveric shoulders with the trapezius anatomically force loaded to normal. The trapezius was then serially transected over 8 trials, which alternated between clavicular defects (CD) and scapular defects (SD); each sequential defect consisted of 25% of the clavicular or scapular trapezial attachment. After each defect, specimens were tested with angle-controlled scapular internal and external rotation (12°) with rotary torque measurements to evaluate ACJ stability.

Results

The mean resistance in rotary torque for 12° of scapular internal rotation (protraction) with native specimens was 7.0 ± 2.0 N·m. Overall, internal rotation demonstrated a significant decrease in ACJ stability with trapezial injury (P < .001). Eight sequential defects resulted in the following significant percentage decreases in rotary torque from native internal rotation: 1.5% (25% CD; 0% SD), 5.6% (25% CD; 25% SD), 5.1% (50% CD; 25% SD), 6.5% (50% CD; 50% SD), 3.8% (75% CD; 50% SD), 7.1% (75% CD; 75% SD), 6.7% (100% CD; 75% SD), and 12.3% (100% CD 100% SD) (P < .001). The mean resistance in rotary torque for 12° of scapular external rotation (retraction) with native specimens was 7.1 ± 1.7 N·m. External rotation did not demonstrate a significant decrease in ACJ stability with trapezial injury (P = .596). The 8 sequential defects resulted in decreases in rotary torque from native external rotation of 0%, 3.8%, 4.0%, 3.2%, 3.5%, 3.4%, 4.2%, and 0.7%.

Conclusion

Trapezial injury resulted in increased instability in the setting of scapular internal rotation (protraction) of the ACJ.

Clinical Relevance

These findings validate the inclusion of deltotrapezial fascial injury consideration in the modified Rockwood classification system. Repair of the trapezial insertion on the ACJ may provide improved outcomes in the setting of ACJ reconstruction.

Differences between Coracoclavicular, Acromioclavicular, or Combined Reconstruction Techniques on the Kinematics of the Shoulder Girdle

BACKGROUND

Although the coracoclavicular (CC) ligaments are classically reconstructed after acromioclavicular (AC) joint injuries, biomechanical studies over the past decade have indicated the importance of an additional reconstruction of the AC ligaments. To date, no kinematic study has investigated the kinematic differences between these reconstruction strategies.

PURPOSE

To evaluate the restoration of shoulder motion after an AC injury using a CC ligament, an AC ligament, or a combined reconstruction technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

After creating a Rockwood grade V lesion in 14 cadaveric shoulders, the AC joint injury was treated with either a CC ligament reconstruction using a suspension device, an in situ AC ligament reconstruction using 2 coupled soft tissue anchors, or a combination of these 2 techniques. Joint motions were registered during humerothoracic elevation in the coronal plane and protraction in the intact shoulder in a Rockwood V lesion and after the 3 reconstruction strategies. An optical navigation system measured 3-dimensional rotation in the sternoclavicular and scapulothoracic joints, and both rotation and translation were analyzed in the AC joint.

RESULTS

In the sternoclavicular joint, the CC and combined reconstruction techniques adequately restored clavicular axial rotation, while the AC reconstruction technique showed a better correction of clavicular elevation. Scapulothoracic joint rotations were best restored by reconstructing the AC ligaments. In the AC joint, the relative tilting position and the lateral rotation of the scapula compared with the clavicle were best restored by the suspension device and combined reconstruction. The AC ligament reconstruction technique demonstrated a better restoration of the relative protracted position and resulted in a better correction of the translation of the scapula relative to the clavicle.

CONCLUSION

This study illustrates that there are kinematic differences between AC, CC, or combined ligament reconstruction strategies. Although each technique was able to restore different elements of the joint kinematics, none of the strategies completely restored the shoulder girdle to its preinjured state.

CLINICAL RELEVANCE

Humerothoracic movements after Rockwood V lesions are best restored using the CC reconstruction technique, and scapulothoracic movements are best restored using the AC ligament reconstruction technique.

Evaluation of Patients with Acromioclavicular Joint Separation Treated Using the Clavicular Hook Plate

BACKGROUND

This study aimed to evaluate the outcomes of patients who underwent surgical treatment using the clavicular hook plate for diagnosed Rockwood Type 3 - Type 4 - Type 5 acromioclavicular joint separation.

MATERIAL AND METHODS

Patients who were operated with the diagnosis of acute traumatic acromioclavicular joint separation between the years 2017-2021 were evaluated retrospectively. Patients&apos; age, gender, mechanism of injury, time to surgery, follow-up duration, and complications were evaluated. Functional results were evalu-ated using pre-op and post-op VAS and the Constant-Murley Shoulder Score.

RESULTS

A total of thirty patients admitted with the diagnosis of acromioclavicular joint separation were included. All patients underwent surgical treatment using the clavicular hook plate. Twenty (66.6%) patients were male and 10 (33.6%) were female. Seventeen of the patients were admitted due to sports injuries, 6 due to traffic accidents, and 7 due to workplace accidents. The patients were followed up for an average of 26.1 weeks. The Rockwood Classification was used for classification of injuries. Accordingly, 12, 13, and 5 of the patients had Type 3, Type 4, and Type 5 injury, respectively. While the mean pre-op VAS score was 7.4 (5-9), it was 1.8 (1-4) in the post-op period. The mean pre-op Constant-Murley score was 31.5 (22-42), compared to 85.1 (72-100) in the post-op period. The differences between the pre-op and post-op VAS and Constant-Murley Shoulder Scores were statistically significant.

CONCLUSION

In this study, we achieved good functional results in the treatment of acromioclavicular joint separation by using a clavicular hook plate providing stable fixation and allowing early mobilization.

Nonoperative Management of Traumatic Acromioclavicular Joint Injury: A Clinical Commentary with Clinical Practice Considerations

Traumatic injuries of the acromioclavicular joint result in pain and potentially long-term alterations in scapulohumeral rhythm that occurs due to disruption of the clavicular strut function which is integral to scapular kinematics. Nonoperative treatment remains a valid option in most acromioclavicular joint injuries with the potential of minimizing pain and restoring scapulohumeral rhythm. However, few studies have provided nonoperative treatment details. Therefore, the purpose of this clinical commentary is to discuss the rationale, indications, and techniques of nonoperative treatment and present an organized approach for evaluating and managing such patients based on the best available evidence. Attention will be focused on identifying the treatment methods employed and the results/outcomes of such treatments.

Level of Evidence

5.

Clinical Evaluation and Instrumental Diagnostics in Acute Acromioclavicular Joint Dislocation

BACKGROUND

The aim was to improve the diagnosis of acromioclavicular joint dislocation by studying the capabilities and characteristics of clinical and instrumental diagnostic methods. The idea is expressed that modern clinical and instrumental diagnostic methods comprise a large number of techniques, but no single algorithm for diagnosing injury to the AC joint has been developed. A gold standard for investigating and diagnosing acute AC joint dislocation does not currently exist.

MATERIALS AND METHODS

A retrospective study of the characteristics and capabilities of clinical and instrumental diagnostic methods was performed in 152 patients with traumatic shoulder pathology. The patients were divided into two groups: Group I of 102 patients (67%) with acromioclavicular joint dislocation type III-VI according to Rockwood classification and Group II of 50 patients (33%) with a partial tear of the rotator cuff. Clinical and instrumental examinations involved specific provocative tests; the radiological diagnostics comprised conventional radiographs with the Zanca, axillary and Alexander views, and CT, MRI, and ultrasound examinations.

RESULTS

The characterization of examination methods was based on the records of patients in Group I and II. The most sensitive clinical test to establish Rockwood type V of acromioclavicular joint dislocation was the Paxinos test (91%). The lowest sensitivity across the tests used was observed with the active compression test to diagnose type IV of dislocation (50%). As regards the X-ray examination, the axial view was 100% sensitive for detecting type IV and VI AC joint dislocation. The Zanca view is highly sensitive for patients with Rockwood type V and Alexander view for Rockwood type III and V dislocations. The accuracy of ultrasound work-up in Group I was 95%, with 96% sensitivity and 93% specificity, while MRI accuracy was 97%, with 96% sensitivity and 98% specificity, and CT accuracy was 81%, with 83% sensitivity and 75% specificity.

CONCLUSIONS

1. Determination of the sensitivity and specificity of the X-ray examination revealed the absence of a 100% effective X-ray view for type III and V AC joint dislocation. 2. The accuracy and sensitivity of the ultrasound, MRI, and CT examinations are high. 3. There is currently no consensus on a protocol to view acute AC joint injuries. 4. Complete and timely early diagnosis of acromioclavicular dislocation allows for a diffe-rentiated approach to surgical treatment tactics, preventing possible complications and restoring the function of the injured shoulder joint to the fullest extent.

Acromioclavicular, Coracoclavicular and Medial Coracoclavicular Ligaments Assessment in Acromioclavicular Dislocation

Objective  To study the anatomy of the medial coracoclavicular ligament and assess the contribution of the acromioclavicular, coracoclavicular and medial coracoclavicular ligaments to the stability of the acromioclavicular joint.

Methods  Twenty-six shoulders from 16 fresh cadavers were dissected after placement in dorsal recumbency with a 15-cm cushion between the shoulder blades. An extended deltopectoral approach was performed proximally and medially, followed by plane dissection and ligament identification. The acromioclavicular and coracoclavicular distances were measured using points previously marked with a millimeter caliper. Six of these specimens were submitted to a biomechanical study. The acromioclavicular ligament, the coracoclavicular ligament and the medial coracoclavicular ligament were sectioned sequentially, and a cephalic force of 20 N was applied to the lateral clavicle. The acromioclavicular and coracoclavicular distances were measured in each of the ligament section stages.

Results  The right medial coracoclavicular ligament presented, on average, 48.9 mm in length and 18.3 mm in width. On the left side, its mean length was 48.65 mm, with a mean width of 17.3 mm. Acromioclavicular, coracoclavicular and medial coracoclavicular ligament section resulted in a statistically significant increase in the coracoclavicular distance and posterior scapular displacement.

Conclusion  The medial coracoclavicular ligament is a true ligamentous structure found in all dissected shoulders. Our results showed that the scapular protraction relaxed the medial coracoclavicular ligament, while scapular retraction tensioned it; in addition, our findings demonstrate that this ligament contributes to the vertical and horizontal stability of the acromioclavicular joint.

Kinematic Alterations in the Shoulder Complex in Rockwood V Acromioclavicular Injuries During Humerothoracic and Scapulothoracic Movements: A Whole-Cadaver Study

BACKGROUND

Previous cadaveric kinematic studies on acromioclavicular injuries described mainly rotational differences during humerothoracic movements. Although isolated scapulothoracic movements are also often performed during activities of daily life and can be painful after acromioclavicular injuries, they have not been extensively studied. Further, the analysis of joint translations in kinematic studies has received little attention compared with biomechanical studies.

HYPOTHESIS

A kinematic analysis of joint motions in the intact shoulder versus a shoulder with Rockwood V injury would demonstrate a different pattern of kinematic alterations during humerothoracic and scapulothoracic movements.

STUDY DESIGN

Descriptive laboratory study.

METHODS

A kinematic analysis was performed in 14 cadaveric shoulders during 3 humerothoracic passive movements (coronal and sagittal plane elevation and horizontal adduction) and 3 scapulothoracic passive movements (protraction, retraction, and shrug). An optical navigation system registered rotational motions in the sternoclavicular, scapulothoracic, and acromioclavicular joints in the intact and Rockwood V conditions. In the acromioclavicular joint, mediolateral, anteroposterior, and superoinferior translations were also analyzed.

RESULTS

In the Rockwood V condition, a significant increase in clavicular elevation in the sternoclavicular joint during both humerothoracic and scapulothoracic movements was demonstrated, whereas a significant decrease in posterior rotation of the clavicle occurred only during humerothoracic movements. In the scapulothoracic joint, the scapular position changed most significantly during protraction. In the acromioclavicular joint, the scapular tilting position was altered significantly during both humerothoracic and scapulothoracic movements, whereas the scapular rotational position changed only during coronal and sagittal plane elevation. The largest significant changes in the scapular protraction position were seen during protraction movement. Further, in the acromioclavicular joint there was a significant inferior translation of the scapula during all motions, a significant anterior translation during protraction and horizontal adduction, and a significant posterior translation during coronal plane elevation. Mediolaterally, the acromial end of the scapula slid further under the distal clavicle during protraction than during horizontal adduction.

CONCLUSION

Large kinematic differences were seen between the intact state and a Rockwood V lesion not only during humerothoracic movements but also during scapulothoracic movements in the cadaveric model. During humerothoracic movements, rotational differences were mainly caused by alterations in the clavicular position. In contrast, during protraction, the alterations in the scapular position were the dominant factor.

CLINICAL RELEVANCE

This study demonstrates that protraction induces larger kinematic alterations than horizontal adduction in acromioclavicular injuries and can therefore be included in both clinical examination and kinematic analyses to identify lesions more clearly.

The association between coracoacromial ligament morphology and rotator cuff tears: A cadaveric study

To determine the association between coracoacromial ligament (CAL) morphology and rotator cuff tears. The present study is a prospective cohort study based on the dissection of 172 shoulders from 86 (46 female, 40 male) formalin embalmed European Caucasian cadavers, with a median age of 82 years. The anatomy of CAL was examined, including its morphology and parametric measurements, while the rotator cuff tendons were inspected for the presence of tears. Gross examination of the CAL in 155 shoulders revealed a variable number of bands as follows: 28 (18%) had one band, 56 (36%) two bands and 71 (46%) three or more bands. Inspection of the rotator cuff tendons showed the presence of tears in 77 (50%) shoulders, of which 37 (24%) were partial and 40 (26%) were full-thickness tears. Statistical analysis showed a significant association (P < 0.05) between CAL band number and the prevalence of a rotator cuff tear. A high proportion of rotator cuff tears were observed in shoulders with two (52%) and three or more CAL bands (56%) compared to single band ligaments (29%). Parametric assessment of the CAL in shoulders with rotator cuff tears showed significantly greater (P < 0.05) attachment widths and ratios, thicker ligament bands, and larger cross-sectional areas compared to the control group. Coracoacromial ligaments with more than a single band have a strong association with rotator cuff tears.

Mid-clavicle fracture with dislocation of the ipsilateral acromioclavicular joint treated with Endobutton system: A case report and review of the literature

RATIONALE

Acromioclavicular joint (ACJ) dislocation combined with ipsilateral midclavicular fracture is extremely unusual and is a high-energy injury to the shoulder. A review of the literature divides the treatment of clavicular fractures is divided into nonsurgical treatment, plates, and intramedullary nailing, while the options for ACJ dislocation are elastic fixation and rigid fixation. However, there is still a lack of consensus about the most appropriate way to treat this shoulder injury. This case report involves a mid-clavicle fracture with dislocation of the ipsilateral ACJ, which was classified as type V according to Rockwood classification.

PATIENT CONCERNS

A 65-year-old man came to the emergency department after a traffic accident in which he was driving a motorcycle that collided with another motorcycle and his right shoulder collided directly with the ground. Digital radiography (DR) and computed tomography (CT) scans of the right shoulder joint showed mid-clavicle fracture with dislocation of the ipsilateral ACJ, which was classified as type V according to Rockwood classification.

DIAGNOSES

The diagnosis of mid-clavicle fracture with dislocation of the ipsilateral ACJ was confirmed by DR and CT.

INTERVENTIONS

The patient was treated with a clavicle plate combined with the double Endobutton technique.

OUTCOMES

After a 6-month follow up, the patient had excellent results for shoulder range of motion and functional. The patient's Constant-Murley score is 92.

LESSONS

Mid-clavicular fracture with a high-energy injury is highly suspicious and requires perfect shoulder CT or bilateral shoulder stress position DR to confirm whether there is a combined ACJ dislocation.

Operative treatment of acute acromioclavicular joint dislocations graded Rockwood III-V: a retrospective and comparative study between three different surgical techniques

BACKGROUND

the optimal treatment of acute type III-V acromioclavicular (A-C) Rockwood dislocations is still a matter of discussion in orthopaedic surgery.

AIM OF THE WORK

retrospective and comparative evaluation of the clinical and radiographic results of three different surgical techniques for stabilization of A-C joint using tension band wiring, hook plate and TightRope.

METHODS

a consecutive series of patients, treated from January 2014 and November 2019, were divided into three groups according to the surgical method used. They were clinically and radiographically assessed and the results were compared with those present in the literature.

RESULTS

66 patients, with a mean age of 44.7 years, were enrolled with a mean follow-up of 37.7 months (range 6-58 months). All patients, regardless of the group, had satisfactory outcome. According to the DASH score, statistically significant difference favours the TightRope Group (TRG) fixation (p<0.005). The TRG showed the highest mean Constant score (96,1); there are no significative differences between the clinical scores of Hook Plate Group (HPG) and Tension Band Wiring Group (TBWG). However, these two methods showed numerous complications, especially metal-work mobilization and stiffness respectively.

CONCLUSIONS

good results can be overall achieved with primary fixation by the three different surgical methods under investigation. The TightRope system exhibited some advantages such as higher clinical scores, early recovery of range of  movements, longitudinal surgical incision with non-keloid scar, no need for a second surgery and lower rate of complications.

Acromioclavicular Joint Injuries: Effective Rehabilitation

Purpose

To perform a review of the literature focusing on rehabilitation protocols in patients with acromioclavicular (AC) joint injuries treated operatively and nonoperatively and to provide an updated rehabilitation treatment algorithm.

Methods

Studies were identified by searching the MEDLINE database from 01/1995 to 09/2020. Included studies contained detailed rehabilitation protocols with physiologic rationale for AC joint injuries. Biomechanical studies, technique articles, radiographic studies, systematic reviews, case studies, editorials, and studies that compared nonoperative versus operative treatment without focus on rehabilitation were excluded. Following identification of the literature, an updated treatment algorithm was created.

Results

The search strategy yielded 1742 studies, of which 1654 studies were excluded based on title, 60 on the abstract, and 25 on the full manuscript. One study was manually identified using article reference lists, yielding four publications presenting detailed rehabilitation protocols based on physiologic rationale. No randomized controlled trials or comparative studies were identified or cited as a basis for these rehabilitation protocols.

Conclusion

Few detailed rehabilitation protocols in patients with AC joint injuries have been published. These protocols are limited by their standardization, arbitrary timelines, and provide minimal assessment of individual patient characteristics. The quality of patient care can be improved with more practical guidelines that are goal-oriented and allow for critical thinking among clinicians to address individual patient needs. Three common barriers preventing successful rehabilitation were identified and addressed: Pain, Apprehension, and (anterior chest wall) Stiffness to regain Scapular control, effectively termed "PASS" for AC joint rehabilitation.

Clinical Relevance

Rehabilitation protocols for AC joint injuries should be less formulaic and instead allow for critical thinking and effective communication among clinicians and therapists to address individual patient needs.

Evaluation of the Circles Measurement and the ABC Classification of Acromioclavicular Joint Injuries

BACKGROUND

Acromioclavicular joint (ACJ) injuries are common. Despite this, it remains unclear how best to assess, classify, and manage these cases. A simple, reliable, valid, and accurate radiographic parameter to measure ACJ displacement would allow improved consistency of diagnosis and subsequent treatment pathways.

PURPOSE

To evaluate "the circles measurement" and associated "ABC classification" as a tool for assessing ACJ displacement and injury classification.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The circles measurement is taken from a lateral Alexander radiograph of the shoulder. The measurement is the center-to-center distance between 2 circles drawn to define the lateral extent of the clavicle and the anteromedial extent of the acromion; it is independent of the displacement plane, judging total ACJ displacement in any direction rather than trying to quantify vertical and/or horizontal displacement. When utilized clinically, the circles measurement is a single measurement calculated as the difference between values recorded for the injured and uninjured sides. Validation of the circles measurement was performed using lateral Alexander radiographs (including ±20° projection error in all planes) and computed tomography of standardized ACJ injury simulations. We assessed inter- and intrarater reliability, convergent validity, and discriminant validity of the circles measurement and subsequently generated a classification of ACJ injury based on displacement.

RESULTS

Reliability and validity of the circles measurement was excellent throughout. Interrater reliability (ICC [intraclass correlation coefficient] [2,1], 95% CI; n = 78; 4 observers) was 0.976 (0.964-0.985). Intrarater reliability (ICC [2,1]; 95% CI; n = 78; 2 measures) was 0.998 (0.996-0.998). Convergent validity (Pearson correlation coefficient, r) was 0.970 for ideal radiographs and 0.889 with ±20° projection error in all planes. Discriminant validity, with 1-way analysis of variance, showed a P value of <.0001 and effect size (η²) of 0.960, with the ability to distinguish between the previously defined stable (Rockwood IIIA) and unstable (Rockwood IIIB) injuries. The results permitted objective, statistically sound parameters for the proposed ABC classification system.

CONCLUSION

The circles measurement is a simple, reliable, valid, accurate, and resilient parameter for assessing ACJ displacement and can be used in conjunction with the proposed ABC classification to define ACJ injuries more accurately and objectively than previously described.

CLINICAL RELEVANCE

This novel parameter has the potential to standardize the initial assessment and possibly the subsequent clinical management of ACJ injuries, in addition to providing a standardized measure for future research.

Clinical Outcome of a Modified Coracoid Tunnel-Free Coracoclavicular Sling Technique With Remnant Preservation for the Treatment of High-Grade Acromioclavicular Joint Separation: A Report of 48 Cases With 2 to 5 Years of Follow-up

BACKGROUND

High-grade acromioclavicular (AC) joint separation injuries (Rockwood type IV or V) are surgically indicated because of complete disruption of the AC and coracoclavicular (CC) ligaments, leading to instability and pain. In surgical techniques that require a suspensory system, coracoid tunnel-related complications are not uncommon.

PURPOSE

To report subjective and objective clinical outcomes and complication rates of a modified coracoid tunnel-free CC sling technique combined with CC ligament remnant preservation for a minimum 2-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 2014 and January 2017, we prospectively enrolled patients who underwent a modified CC sling technique performed by 1 senior surgeon using the AC TightRope System in a coracoid tunnel-free fashion. The CC distance (CCD) and Rockwood AC joint classification were evaluated on radiographs preoperatively, immediately postoperatively, and at the final follow-up. The visual analog pain score, range of motion, American Shoulder and Elbow Surgeons score, Constant-Murley score, and University of California Los Angeles score were recorded preoperatively and at the final follow-up.

RESULTS

In total, 48 of 54 patients (88.9%) were included for the evaluation with a mean ± SD follow-up of 39.3 ± 8.9 months (range, 24.7-64.3 months). The CCD was significantly decreased from 22.7 ± 4.2 to 9.8 ± 2.3 mm (P < .01) immediately after surgery and to 11.2 ± 1.8 mm (P < .01) at final follow-up. At the final follow-up, the side-to-side difference of CCD was 3.5 ± 0.6 mm. Compared with the preoperative level, all subjective evaluations were significantly improved at the final follow-up. We observed that 4 of the 48 patients (8.3%) had a loss of reduction at the final follow-up, but no pain or instability was documented. Further, no coracoid-related complication or other complications were recorded.

CONCLUSION

The coracoid tunnel-free CC sling technique using the AC TightRope System combined with CC ligament remnant preservation demonstrated significant improvement regarding both clinical and radiological outcomes, with a reduction loss rate of 8.3%. It is a safe method that could achieve satisfactory result without any coracoid drilling-related complications.

Comparison of the Results of Hook Plate and Endo-Button Used in the Surgical Treatment of Acromioclavicular Joint Separation

Purpose: Our study aimed to compare the clinical outcomes between endo-button and hook plate fixations for the treatment of acute unstable acromioclavicular (AC) joint dislocation.

Materials: A retrospective evaluation of patients with acute AC joint dislocation who were treated between February 2009 and December 2019 was performed. The study was conducted with 39 patients who met the inclusion criteria. Patients were divided into group 1, operated with a hook plate, and group 2, operated with an endo-button. The demographic features and postoperative complications were analyzed. The disability of arm, shoulder, and hand (DASH) scoring system, modified University of California at Los Angeles shoulder score (UCLA) scale, and the visual analog scale (VAS) scores were used to evaluate shoulder functions in these patients. Shoulder functions were evaluated one, three, six, and twelve months after surgery.

Results: There were 21 patients in group 1 and 18 patients in group 2. Gender distribution was 28 male and 11 female, and the average age was 30.9 years (18-50). There were no significant differences in age, sex, side of injury, or follow-up time from injury to surgery between the two groups. The UCLA scores of group 1 and group 2 one month after surgery were 17.2 and 27.2, respectively. DASH scores of group 1 and group 2 one month after surgery were 82 and 52, respectively. The VAS scores of group 1 and group 2 one month after surgery were 70 and 14, respectively. For all scores at first month post-surgery, there were statistically significant differences between groups, but scores became similar 12 months after surgery.

Conclusion: Postoperative shoulder scores of patients with endo-button showed superiority in the early stages. However, after a year of follow-up, the results of the surgery performed with an endo-button or a hook plate were similar.

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.

Acromioclavicular Joint Injuries in Professional Ice Hockey Players: Epidemiologic and MRI Findings and Association With Return to Play

Background:

Acromioclavicular joint (ACJ) injuries are common in ice hockey players and are traditionally evaluated with conventional radiography, which has recognized limitations in the accurate characterization of the spectrum of soft tissue injuries and severity/grade of injury sustained.

Purpose:

To evaluate the epidemiologic, clinical, and magnetic resonance imaging (MRI) findings in professional ice hockey players who have sustained acute ACJ injuries.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective review was performed of professional National Hockey League (NHL) players referred for MRI evaluation of acute ACJ injuries. All MRI scans were assessed for status of the ACJ, ligamentous stabilizers, and surrounding musculature. MRI-based overall grade of ACJ injury (modified Rockwood grade 1-6) was assigned to each case. Data regarding mechanism of injury, player handedness, clinical features, and return to play were evaluated.

Results:

Overall, 24 MRI examinations of acute ACJ injuries (23 patients; mean age, 24 years) were reviewed. We found that 50% of injuries were sustained during the first period of play, and in 75% of cases, injuries involved the same side as player shooting handedness. Analysis of MRI scans revealed 29% (7/24) grade 1 ACJ injuries, 46% (11/24) grade 2 injuries, 21% (5/24) grade 3 injuries, and 4% (1/24) grade 5 injuries. Trapezius muscle strains were seen in 79% and deltoid muscle strain in 50% of cases. Nonoperative management was used for 23 injuries; 1 patient (grade 5 injury) underwent acute reconstructive surgery. All players successfully returned to professional NHL competition. Excluding cases with additional injuries or surgery (n = 3) or convalescence extending into the offseason (n = 3), we found that the mean return to play was 21.4 days (7.2 games missed). No statistically significant difference was observed in return to play between nonoperatively treated grade 3 injuries (mean, 28.3 days) and grade 1 or 2 injuries (mean, 20.1 days). However, grade 3 injuries were associated with a greater number of NHL scheduled games missed (mean, 12.7) compared with lower grade injuries (mean, 6.1) (P = .027).

Conclusion:

The spectrum of pathology and grading of acute ACJ injuries sustained in professional ice hockey can be accurately assessed with MRI; the majority of injuries observed in this study were low grade (grades 1 and 2). Although grade 3 injuries were associated with a greater number of games missed, similar return-to-play results were observed between nonoperatively treated grade 3 and grade 1 or 2 ACJ injuries.

Sagittal orientation of coracoclavicular ligament reconstruction affects the stability of surgical repair

BACKGROUND

The variation in the anatomic relationship between the coracoid and the clavicle affects the biomechanical stability of coracoclavicular ligament reconstruction (CCLR).

METHODS

Three-dimensional computed tomography reconstruction of 85 patients was analyzed. Anatomic landmarks were used to derive the coracoclavicular sagittal reconstruction angle (sRA). The lateral concave angle, which indicated the shape of the distal clavicle, and the offsets between the clavicle and coracoid were also measured. To investigate the biomechanical effects of the sRA on CCLR, 7 computed tomography scans with different sRAs were 3D printed. Two reconstructions, a single trans-coracoclavicular tunnel and a looped reconstruction technique, were performed sequentially. Models were cyclically loaded at 70 N in the anterior, posterior, and superior directions.

RESULTS

The mean sRA was 68° ± 9.3° (range, 47°-85°). The superoinferior offset between the clavicle and the coracoid and the lateral concave angle positively correlated with the sRA (r = 0.359 and 0.837, respectively; P ≤ .001), whereas the anteroposterior offset had a negative correlation (r = -0.925; P < .001). The sRA had a negative correlation with the anterior displacement of the clavicle (rho = -0.96; P < .001) and a positive correlation with the posterior displacement for both surgical techniques (rho = 1.0; P < .001).

CONCLUSION

The anatomic orientation of the native coracoclavicular ligaments is highly variable in the sagittal plane. Low sagittal angles can reduce anterior stability, whereas high sagittal angles can reduce posterior stability of CCLR.

Acromioclavicular joint injuries: Imaging and management

Acromioclavicular joint injuries are commonly encountered in the setting of shoulder trauma. Knowledge of the anatomy and biomechanics of the joint, grading of joint injuries, and understanding the capabilities and limitations of different radiological modalities will help in selecting the best management option and outcomes for affected patients.

Septic arthritis of the acromioclavicular joint: a case series and review of the literature

OBJECTIVE

To report a case series of three patients with septic arthritis of the acromioclavicular joint and a review of the literature for this condition. Additionally, we developed an algorithm for diagnosing and treating septic arthritis of the acromioclavicular joint.

METHODS

A retrospective review of patients treated at our institution for septic arthritis of the acromioclavicular joint during the collection period was performed and three cases were identified. A review of the English literature on this rare condition was also performed with only 28 cases being identified.

RESULTS

A series of three consecutive patients were treated for septic acromioclavicular arthritis with resolution of the infection. Two patients underwent open surgical debridement and one underwent aspiration. All patients were treated with a minimum of six weeks of tailored intravenous antibiotic therapy.

CONCLUSION

Septic arthritis of the acromioclavicular joint can be difficult to diagnose and requires a high index of suspicion. Surgical debridement, open or arthroscopic, with tailored antibiotic therapy is an effective means for the management of septic arthritis of the acromioclavicular joint. In patients who are unable to have surgical debridement, aspiration and tailored antibiotics have been shown to be effective.

Innervation of the acromioclavicular joint by the suprascapular nerve

BACKGROUND

The suprascapular nerve is largely responsible for the majority of the sensory innervation of the acromioclavicular joint. In this anatomical study, we describe, in detail, the anatomy of the sensory innervation of the acromioclavicular joint by the branches of the suprascapular nerve.

METHODS

Twenty-seven shoulders from 17 cadaveric specimens were carefully dissected to identify the course of the suprascapular nerve, with the main focus being on the sensory innervation of the acromioclavicular joint. Nine specific measurements of the acromioclavicular joint sensory nerves were made of each shoulder in relation to distinct anatomical landmarks to determine the mean location and course of these nerves.

RESULTS

In all 27 shoulders (100%), a sensory branch to the acromioclavicular joint with a proximal origin from the suprascapular nerve could be depicted ("first sensory branch"). The mean length of this branch was 4.3 cm (range: 3.3-5.3 cm). In 14 shoulders (52%), a further sensory branch of the suprascapular nerve innervating the posterior acromioclavicular joint capsule could be identified ("second sensory branch").

DISCUSSION

A detailed anatomical description of the sensory innervation of the acromioclavicular joint from suprascapular nerve branches was performed, which can potentially aid in the development of more focused anesthetic blockades and acromioclavicular joint denervation procedures.

Medium- to long-term results of acromioclavicular joint stabilisation using the Ligament Augmentation Reconstruction System (LARS) ligament

BACKGROUND

Opinion is divided as to optimum management of grade III acromioclavicular joint injuries that have failed conservative management. We objectively investigated the radiological and functional outcome of acromioclavicular joint reconstruction using the Ligament Augmentation Reconstruction System (LARS®).

METHODS

Retrospective review of patients with LARS reconstruction of acromioclavicular joint dislocations with minimum six-year follow-up. Functional assessment was performed using the constant score, Disability of Arm Shoulder and Hand score and simple satisfaction score. Radiological assessment was undertaken using plain radiographs. Results were compared with the uninjured limb.

RESULTS

Twenty-four of 25 patients were included. Mean constant score for the injured shoulder was 87.0, Disability of Arm Shoulder and Hand score was 11.6. All patients indicated that they would have the operation again. There were five complications including two patients that suffered small cracks in the clavicle. Coracoid erosion was frequently seen but was most often minor. In two cases, this resulted in a complete dissociation of the coracoid tip but without functional detriment.

DISCUSSION

LARS is a safe and effective method of acromioclavicular joint reconstruction producing good results, and we recommend its use for these injuries. We also caution clinicians who use cerclage methods to be aware of coracoid erosion when following up their patients.

Biomechanical evaluation of an independent acromioclavicular ligament repair for acromioclavicular joint reconstruction

BACKGROUND

A number of surgical techniques for the treatment of acromioclavicular joint separations have been described; however, few have been able to create a strong intra-operative construct that provides minimal joint translation. A biomechanical study was conducted to examine joint translation in an independent acromioclavicular ligament repair.

METHODS

Three variations of a novel independent acromioclavicular ligament repair technique underwent testing using a Sawbones model. The technique involves threading sutures through two acromial bone tunnels in a suture-bridge configuration and anchoring them into the distal clavicle. Three groups of eight specimens underwent reconstruction; group 1 using FiberTape, group 2 using FiberWire and group 3 using FiberTape in a modified (under-over) suture-bridge configuration. Superior, anterior and posterior translation was tested at loads of 10, 20 and 30 N.

RESULTS

Group 3 repair yielded the least translation in both anterior-posterior and superior-inferior planes, with a two-fold decrease in superior translation compared to groups 1 and 2 (P < .05). Both groups 1 and 3 using FiberTape resulted in significantly less anterior and posterior translation compared to the FiberWire group (P < .05).

DISCUSSION

The independent acromioclavicular ligament repair, without repair of the coracoclavicular ligament, demonstrated significant translational stability in the anterior-posterior and superior-inferior planes.

The medium-term results of acromioclavicular joint arthroscopy with chondral and meniscal debridement

PURPOSE

Surgical management of a young patient with a stable but painful acromioclavicular (AC) joint but normal imagining is a challenging problem. A standard arthroscopic excision of distal clavicle seems too aggressive. An alternative procedure is arthroscopic debridement of the joint, particularly the often torn meniscus, and chondroplasty. This study demonstrates in younger patients the medium-term result of arthroscopic debridement of a painful AC joint.

METHODS

Fifty-three young adult patients with a stable but painful AC joint, and virtually normal magnetic resonance imaging (MRI) scan, had arthroscopic debridement of the AC joint. Follow-up was with questionnaire and American Shoulder and Elbow Surgeons Shoulder Score (ASES).

RESULTS

Mean age was 29 years (18-39), 41 male, 31 dominant arm. Twenty-two patients demonstrated additional shoulder pathology. Two patients had a later distal clavicle excision. Five patients had later surgery to other areas of the shoulder but had an asymptomatic AC joint. Thirty-eight patients completed the ASES questionnaire at mean 44 months (24-86) post-operation. The mean ASES score was 82.8 (52-100). There was no association between ASES score and AC joint disease severity found at operation ( p = 0.25). Seven patients had ongoing shoulder symptoms, although none were severe enough to warrant any treatment.

CONCLUSION

In this young group of patients with arthroscopic AC joint debridement, most had good relief of the AC joint related symptoms. This is a worthwhile procedure in the young patient, with quick recovery, and does not preclude further AC joint surgery later.

Traumatic Floating Clavicle: Is This a Rare Injury?

Bipolar clavicle dislocation is thought to be a rare injury pattern. Even experienced orthopaedic surgeons may have not come across this entity during their careers. We report a misdiagnosed case of a 65-year-old male who underwent a motorcycle accident and was surgically treated six months post-injury. This case has been the ground for research since then. We have come to the conclusion that this type of injury is probably not so uncommon as previously thought. Careful evaluation is of immense importance during diagnosis protocol, and practitioners should be aware of this injury pattern in order to avoid misdiagnosis.

Horizontal Instability of the Acromioclavicular Joint: A Systematic Review

BACKGROUND

Injuries to the acromioclavicular (AC) joint are common and should be suspected in patients who have shoulder pain in the region of the acromion and clavicle. Injuries to the AC ligament can cause horizontal instability and are often neglected or underdiagnosed, which can lead to poor patient outcomes.

PURPOSE

To perform a systematic review of the literature on the diagnosis and treatment of horizontal instability of the AC joint.

STUDY DESIGN

Systematic review.

METHODS

The authors performed a systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies that investigated diagnosis, treatment, and failure of operative management of acute and chronic AC separations. Studies that did not specifically evaluate AC joint injuries, were not written in English, or were specific only to vertical instability of the AC joint were excluded.

RESULTS

Overall, 23 articles met the inclusion criteria and were therefore included in this systematic review. Diagnosing horizontal AC instability is difficult using plain radiographs; dynamic views were shown in some cases to better detect horizontal instability than with static views. More than 60 procedures for treating AC joint injuries have been published, but many focus on vertical rather than horizontal instability. Modifications to current surgical procedures to incorporate reconstruction of the horizontal component showed improved patient outcomes. Such modifications included additional AC joint suture cord cerclage, combined AC and coracoclavicular ligament reconstruction, and the Twin Tail TightRope triple button technique. Failure after surgical stabilization of AC joint separation has been reported to occur in 15% to 80% of cases.

CONCLUSION

No consensus is available regarding the best practices for diagnosis, evaluation, and treatment of acute or chronic horizontal instability of the AC joint. Moreover, horizontal instability injuries are often neglected or poorly understood, making diagnosis difficult, which may lead to high complication rates and failure after surgical stabilization.

Functional and Radiological Outcomes of the Surgical Treatment of Acute Acromioclavicular Dislocation with Anchors Associated with Clavicle and Scapula Fixation

Objective  To evaluate the clinical, radiological and functional results of the surgical treatment of acute acromioclavicular dislocation using a coracoclavicular fixation technique (syndesmopexy) with two metallic anchors, temporary clavicle and scapula fixation, and transfer of the coracoacromial ligament.

Methods  Longitudinal observational study of 30 patients with diagnoses of acute acromioclavicular dislocation, who were submitted to surgical treatment with a minimum follow-up of six months, and who were evaluated clinically, radiologically, and by the University of California at Los Angeles (UCLA), the Disabilities of the Arm, Shoulder and Hand (DASH) and the Constant-Murley functional scores.

Results  The mean values of the scores were: UCLA = 32; DASH = 11.21; and Constant-Murley = 86.93, with satisfactory results higher than 80%. The unsatisfactory results were associated with acromioclavicular pain on palpation, positive subacromial impingement tests, and older age group, presenting statistical significance ( p  < 0.05). Radiologically, higher values on account of the coracoclavicular distance ratio from the operated shoulder compared to the normal shoulder were related to worse outcomes, but with no statistically significant difference. No associations were found between the results of the functional scores and the variables degree of the injury, coracoacromial ligament transfer, clinical impression of loss of reduction and scapulothoracic dyskinesis.

Conclusion  The technique used provides an efficient fixation, with a high level of satisfaction according to the UCLA, Constant-Murley and DASH scores; moreover, it has a low complication rate, despite the high rate of residual radiological acromioclavicular subluxation.

Current evidence for nonpharmacological interventions and criteria for surgical management of persistent acromioclavicular joint osteoarthritis: A systematic review

BACKGROUND

The primary aim of this systematic review was to investigate the individual/combined effectiveness of nonpharmacological interventions in individuals with persistent acromioclavicular joint osteoarthritis. The secondary aims were to investigate the comparative effectiveness of nonpharmacological versus surgical interventions, and to identify the criteria used for defining failure of conservative interventions in individuals who require surgery for persistent acromioclavicular joint osteoarthritis.

METHOD

Major electronic databases were searched from inception until October 2018. Studies involving adults aged 16 years and older, diagnosed clinically and radiologically with isolated acromioclavicular joint osteoarthritis for at least three months or more were included. Studies must explicitly state the type and duration of conservative interventions. Methodological risk of bias was assessed using the Modified Downs and Black checklist.

RESULTS

Ten surgical intervention studies were included for final synthesis. No studies investigated the effectiveness of nonpharmacological interventions or compared them with surgical interventions. Common nonpharmacological interventions trialed from the 10 included studies were activity modification (n = 8) and physiotherapy (n = 4). Four to six months was the most often reported timeframe defining failure of conservative management (range 3-12 months).

CONCLUSIONS

Currently, there is no evidence to guide clinicians about the individual or combined effectiveness of nonpharmacological interventions for individuals with persistent acromioclavicular joint osteoarthritis.

Clavicle Elevation or Shoulder Girdle Depression in Acromioclavicular Joint Dislocation: A Radiological Investigation

Background:

The side-comparative coracoclavicular (CC) distance is used to describe the vertical instability component of acute acromioclavicular (AC) joint dislocations. Elevation of the clavicle or a depression of the shoulder girdle can lead to an increased CC distance. The dislocation direction has not yet been investigated and is not included in common classification systems.

Hypothesis:

Clavicle elevation is primarily responsible for vertical dislocation in AC joint separation.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Weighted and nonweighted bilateral plain anteroposterior views of the shoulder girdles of patients with AC joint dislocations (Rockwood [RW] types III and V), diagnosed in our trauma department between 2001 and 2018, were included in this study. After determining the CC distance, a side-comparative determination of the positions of both the clavicle and shoulder girdle, with reference to the spinal column, was conducted.

Results:

In total, 245 bilateral plain anteroposterior views were evaluated (RW III, n = 116; RW V, n = 129). All patients showed a side-comparative clavicle elevation (mean ± SD: RW III, 5 ± 14 mm; RW V, 11 ± 17 mm) in weighted and nonweighted views. While no depression of the shoulder girdle was measured in RW III injuries (weighted and nonweighted views, 0 ± 11 mm), dropping of the shoulder girdle in RW V lesions on nonweighted views was observed (–5 ± 11 mm).

Conclusion:

Vertical dislocation is mostly associated with clavicle elevation in RW III injures, while in high-grade AC joint dislocations (RW V), a combination of clavicle elevation and shoulder girdle depression is present. A significantly greater superior displacement of the clavicle in RW V injuries was seen in weighted views, while a depression of the shoulder girdle could be detected in nonweighted views. For the first time, these results include the dislocation direction in the classification of an AC joint injury. Further studies are needed to investigate the extent to which dislocation types differ in optimal therapy and outcome.

Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques

BACKGROUND

Acromioclavicular (AC) instability is a frequent injury affecting young and athletic populations. Symptomatic, high-grade dislocations may be managed by a myriad of operative techniques that utilize different grafts to achieve reduction. Comparative data are lacking on the ability of these techniques to achieve excellent patient outcomes and stable AC reduction and to minimize complications.

PURPOSE

To systematically review the outcomes and complications of different techniques of AC joint reconstruction.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The MEDLINE, Scopus, Embase, and Cochrane Library databases were accessed to perform a systematic review of the scientific literature from 2000 to 2018 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following keywords: "acromioclavicular" and "reconstruction." Included articles were evaluated for loss of reduction, complication rate, revision rate, and change in coracoclavicular distance. Articles were stratified by graft and surgical material used: suture only, Endobutton with suture, TightRope, GraftRope, synthetic artificial ligament, tendon graft, and Weaver-Dunn coracoacromial ligament transfer. These outcomes were pooled using a random-effects model and stratified by surgical technique and arthroscopic versus open reconstruction.

RESULTS

Fifty-eight articles were included in the analysis, with 63 homogeneous populations composed of 1704 patients. The mean age was 37.1 years (range, 15-80 years) with a mean follow-up of 34.3 months (range, 1.5-186 months). The overall failure rate was 20.8% (95% CI, 16.9%-25.2%). The overall pooled complication rate was 14.2% (95% CI, 10.5%-18.8%). The most common complications were infection (6.3% [95% CI, 4.7%-8.2%]), fracture to the coracoid or distal clavicle (5.7% [95% CI, 4.3%-7.6%]), and hardware/button failure (4.2% [95% CI, 3.1%-5.8%]). There were no differences between arthroscopic and open techniques in regard to loss of reduction (P = .858), overall complication rate (P = .774), and revision rate (P = .390). Open surgery had a greater rate of clavicular/coracoid fractures than arthroscopic surgery (P = .048). Heterogeneity, best assessed from the pooled loss of reduction, was measured as I² = 64.0%.

CONCLUSION

Open and arthroscopic AC joint reconstruction techniques have no differences in loss of reduction, the complication rate, and the revision rate based on the available literature. Complications are significant, and profiles vary between surgical techniques, which should be evaluated in the decision making of selecting the technique.