Prognostic factors to succeed in surgical treatment of chronic acromioclavicular dislocations

INTRODUCTION

Treatment of chronic acromioclavicular joint dislocation (ACJD) remains a poorly known and controversial subject. Given the many surgical options, it is not always easy to determine which steps are indispensable.

METHODS

This article reports a multicenter prospective study. The clinical and radiological follow-up involved a comparative analysis of the preoperative and postoperative data at 1 year, including pain (visual analogue scale), subjective functional incapacity (QuickDASH), and the objective Constant score, as well as a comparative analysis of vertical and horizontal movements measured on simple x-rays.

RESULTS

Based on a series of 140 operated ACJDs, we included 24 chronic ACJDs. The mean time to surgery was 46 weeks (range, 1 month to 4 years). The patients' mean age was 41 years, with a majority of males (75%), 72% of whom participated in recreational sports. Professionally, 40% of the subjects had jobs involving manual labor. We noted 40% grade III, 24% grade IV, and 36% grade V injury according to the Rockwood classification. In 92% of cases, coracoclavicular stabilization was provided by a double button implant, reinforced with a biological graft in 88% of the cases. In 29%, millimeters to centimeters of the distal clavicle were resected and acromioclavicular stabilization was associated in 54%. We observed complications in 33% of the cases. At 1 year postoperative, 21 patients underwent clinical and radiological follow-up (87.5%). Only 35% of the patients were satisfied or very satisfied, whereas 100% of them would recommend the operation. Full-time work was resumed in 91% of the cases and all sports could be resumed in 86%. The pre- and postoperative values at 1 year changed as follows: the mean Constant score improved from 61 to 87 (p=0.00002); the subjective QuickDASH score decreased from 41 to 9 (p=0.00002); and radiologically significant reduction of the initial displacement was observed in the vertical plane (p<10(-3)) and the horizontal plane (p=0.022).

CONCLUSION

In this study, the favorable prognostic factors found were: time to surgery less than 3 months (p=0.02), associated acromioclavicular stabilization, and postoperative immobilization with a sling extended to 6 weeks. However, resection of the distal clavicle did not influence the final result.

LEVEL OF PROOF

Level II prospective non-randomized comparative study.

Is coracoclavicular stabilisation alone sufficient for the endoscopic treatment of severe acromioclavicular joint dislocation (Rockwood types III, IV, and V)?

BACKGROUND

The primary objective was to evaluate correlations linking anatomical to functional outcomes after endoscopically assisted repair of acute acromioclavicular joint dislocation (ACJD).

HYPOTHESIS

Combined acromioclavicular and coracoclavicular stabilisation improves radiological outcomes compared to coracoclavicular stabilisation alone.

MATERIAL AND METHODS

A prospective multicentre study was performed. Clinical outcome measures were pain intensity on a visual analogue scale (VAS), subjective functional impairment (QuickDASH score), and Constant's score. Anatomical outcomes were assessed on standard radiographs (anteroposterior view of the acromioclavicular girdle and bilateral axillary views) obtained preoperatively and postoperatively and on postoperative dynamic radiographs taken as described by Tauber et al.

RESULTS

Of 116 patients with acute ACJD included in the study, 48% had type III, 30% type IV, and 22% type V ACJD according to the Rockwood classification. Coracoclavicular stabilisation was achieved using a double endobutton in 93% of patients, and concomitant acromioclavicular stabilisation was performed in 50% of patients. The objective functional outcome was good, with an unweighted Constant's score ≥ 85/100 and a subjective QuickDASH functional disability score ≤ 10 in 75% of patients. The radiographic analysis showed significant improvements from the preoperative to the 1-year postoperative values in the vertical plane (decrease in the coracoclavicular ratio from 214 to 128%, p=10(-6)) and in the horizontal plane (decrease in posterior displacement from 4 to 0mm, p=5×10(-5)). The anatomical outcome correlated significantly with the functional outcome (absolute R value=0.19 and p=0.045). We found no statistically significant differences across the various types of constructs used. Intra-operative control of the acromioclavicular joint did not improve the result. Implantation of a biological graft significantly improved both the anatomical outcome in the vertical plane (p=0.04) and acromioclavicular stabilisation in the horizontal plane (p=0.02). The coracoclavicular ratio on the anteroposterior radiograph was adversely affected by a longer time from injury to surgery (p=0.02) and by a higher body mass index (BMI) (p=0.006). High BMI also had a negative effect on the difference in the distance separating the anterior edge of the acromion from the anterior edge of the clavicle between the injured and uninjured sides, as assessed on the axillary views (p=0.009).

CONCLUSION

This study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromioclavicular joint. Coracoclavicular stabilisation alone is not sufficient, regardless of the type of implant used. Implantation of a biological graft should be considered when the time from injury to surgery is longer than 10days. The weight of the upper limb should be taken into account, with 6weeks of immobilisation to unload the construct in patients who have high BMI values.

LEVEL OF EVIDENCE

II, prospective non-randomised comparative study.

[Femoral shaft fracture in children: treatment with early spica cast]

PURPOSE OF THE STUDY

Fractures of the femoral shaft are frequent in children and prognosis is good. For children aged less than 7 years, most authors propose orthopedic treatment using prolonged traction then cast immobilization, or orthopedic reduction under general anesthesia and early cast immobilization. The purpose of the present work was to analyze results of orthopedic treatment using a spica early for children aged less than 7 years in comparison with other published series with similar age or management.

MATERIAL AND METHOD

Forty-seven unselected children aged less than 7 years with a closed fracture of the femoral shaft were treated by orthopedic reduction under general anesthesia and immobilization with a spica cast after a short period (<48 hr) of traction in the plane of the bed. Hip immobilization was set in flexion and minimal abduction, knee in flexion. The children were discharged the day the cast was installed or the next day. Follow-up examinations (tolerance) with x-rays cast in place were scheduled for day 8 and day 15. Clinical and radiological assessment was also recorded at removal of the cast, at 3 months, at 1 year, and at maximum follow-up.

RESULTS

Mean age was 37 months (range 2-83 months). Boys predominated (n=34, 73%). Mean duration of traction was 1.13 days (range 0-5 days). Mean duration of cast immobilization was 45.4 days (range 28-78 days). Mean hospital stay was 2.8 days (range 1-10 days). Four patients (8%) were rehospitalized for secondary displacement under the cast. Weight bearing was effective at day 49 (range 33-78). Mean follow-up was 12.1 months (range 3 months-6 years). Five children (10.5%) developed leg length discrepancy greater than 10 mm. The anatomic axis of the femur in the saggital and frontal planes exhibited deviation in 7 children measuring less than 8 degrees in all cases.

DISCUSSION

The localization and type of fracture observed in this series of children was similar to that reported in epidemiological studies. There were no treatment-related complications. In respect to healing time, deviation, and residual leg length discrepancy, results in this series were equivalent to those reported by others, irrespective of the treatment method employed. The major advantage of early spica is a short hospital stay allowing cost containment and rapid return to the child's everyday environment.

Scapulothoracic arthrodesis in facioscapulohumeral muscular dystrophy

Forty-nine scapulothoracic arthrodeses were done in 33 patients with facioscapulohumeral muscular dystrophy to improve upper limb performance during activities of daily living. Mean followup was 102 months (range, 12-257 months). An initial average increase in shoulder abduction of 25 degrees and forward elevation of 29 degrees was seen. Complications included pleural effusion in four patients, atelectasis in one patient, stress fractures in both scapulas in one patient, asymptomatic fractures of the two lower wired ribs in one patient, and spontaneously reversible neurologic complications in two patients. No effect on respiratory function was seen.