The management of acute acromioclavicular dislocation. A randomised prospective controlled trial

Safety zone for posterosuperior shoulder access: study on cadavers

Objective

The posterosuperior shoulder access used in surgical treatment for acromioclavicular dislocation was constructed through dissection of 20 shoulders from 10 recently chilled adult cadavers, and the distances from this route to the nearby neurovascular structures were analyzed.

Methods

A Kirschner wire was introduced into the top of the base of the coracoid process through the posterosuperior shoulder access, in the area of the origin of the conoid and trapezoid ligaments, thus reproducing the path for inserting two anchors for anatomical reconstruction of the coracoclavicular ligaments. The smallest distance from the insertion point of the Kirschner wire to the suprascapular nerve and artery/vein was measured.

Results

The mean distance from the suprascapular nerve to the origin of the coracoclavicular ligaments at the top of the base of the coracoid process was 18.10 mm (range: 13.77–22.80) in the right shoulder and 18.19 mm (range: 12.59–23.75) in the left shoulder. The mean distance from the suprascapular artery/vein to the origin of the coracoclavicular ligaments was 13.10 mm (range: 9.28–15.44) in the right shoulder and 14.11 mm (range: 8.83–18.89) in the left shoulder. Comparison between the contralateral sides did not show any statistical difference.

Conclusion

The posterosuperior shoulder access route for anatomical reconstruction of the coracoclavicular ligaments in treating acromioclavicular dislocation should be performed respecting the minimum limit of 8.83 mm medially.

Operative Fixation of Chronic Acromioclavicular Joint Dislocation With Hook Plate and Modified Ligament Transfer

PURPOSE

The optimal treatment for acute dislocation of the acromioclavicular (AC) joint remains unclear, and prior randomized trials did not reveal any significant improvements in the operative groups. However, it is clear that some patients treated nonoperatively are dissatisfied with their outcome and request surgical correction. This video demonstrates one method of repair of a chronic dislocation of the AC joint in a patient with significant symptomatology following nonoperative treatment of a high-grade AC dislocation.

METHODS

This video demonstrates the open reduction of a chronically dislocated AC joint. After mobilization of the distal clavicle and debridement of the joint, a step cut is made in the anterior surface of the distal clavicle. The coracoacromial (CA) ligament is then identified and mobilized, taking care to preserve its acromial origin. An anterior acromioplasty is then performed with a microsaggital saw. The AC joint is reduced, and the acromial fragment is sculpted to fit the step cut in the distal clavicle, where it is then fixed with a small-fragment cancellous screw in lag fashion. The blade of the hook plate is then contoured to fit under the acromion (posteriorly) to hold the joint in a reduced position. The deltoid is repaired with number 1 absorbable sutures, followed by a standard closure.

RESULTS

Results are improved and complications minimized when care is taken to not avoid overreduction of the clavicle: an intraoperative radiograph, and/or comparison to the opposite side, may be useful. We do not shorten or resect the entire distal clavicle: this has been shown to lead to worse outcomes. We have found that CA transfer with a fragment of attached acromial bone results in more reliable healing than a CA transfer alone (the Weaver-Dunn transfer).

DISCUSSION

In the setting of a chronic AC dislocation, hook plate fixation provides excellent reduction of the joint and a stable mechanical environment: this allows for the optimal healing of the ligament transfer. Typically, 6-12 months postoperatively, the hook plate can be removed to improve motion and reduce local irritation because joint stability is then provided by the transfer with bone-to-bone healing.

Comparison of the outcome of early and delayed surgical treatment of complete acromioclavicular joint dislocation

PURPOSE

The aim of this study is to compare the clinical and radiographic results and the complication rate between early and delayed surgical treatment of acromioclavicular joint (ACJ) dislocation.

METHODS

Publications in the management of ACJ dislocation are identified from the PubMed database between January 1993 and December 2013 using "acromioclavicular joint" and "dislocation" as keywords. The eligibility criteria included are as follows: (1) ACJ dislocation; (2) intervention, early compared with delayed surgical treatment or the surgical treatment for acute compared with chronic ACJ dislocation; (3) human; and (4) English articles. Exclusion criteria consist of the following: (1) type I and type II ACJ dislocation, (2) no definition of the time of early and delayed surgery in studies, (3) no comparison between the clinical result of early and delayed surgery in studies, (4) laboratory studies, radiographic studies, biomechanical studies, (5) the cases including fractures or revisions in studies, and (6) systematic analyses.

RESULTS

Eight studies comparing early and delayed surgical treatment of ACJ dislocation are included in this systematic review. According to Constant scores and shoulder subjective value, early surgery has better functional outcomes than delayed surgery in the treatment of ACJ dislocation (P < 0.05). Partial-dislocation/re-dislocation is found at 26.0 % in early and 38.1 % in delayed surgical treatment (P < 0.05). The rate of CC ossification in early surgical treatment is found as the same as the delayed. The complication rates are found at 12.5 % in early surgical treatment and 17.7 % in the delayed, which is not significantly different.

CONCLUSION

Early surgical treatment may have superiority to the delayed procedure in the management of ACJ dislocation with better functional outcomes and more satisfied reduction. However, high-quality evidence studies are required to provide stronger support for this opinion in the future.

LEVEL OF EVIDENCE

IV.

Surgical treatment of acute acromioclavicular joint dislocations: hook plate versus minimally invasive reconstruction

PURPOSE

This study was performed to compare the clinical results of a minimally invasive technique for acute acromioclavicular (AC) joint dislocation repair with the traditional hook plate fixation.

METHODS

Forty-four patients with an acute (within 2 weeks after trauma) complete AC joint separation (35 male, nine female; median age 36.2 years, range 18-56) underwent surgical repair with either a minimally invasive AC joint repair or a conventional hook plate. Functional outcome was evaluated using the Constant-Murley Score (CMS), the TAFT score and the AC joint instability score (ACJI). Radiographic evaluation was performed with bilateral anterior-posterior (a.p.) stress and Alexander views.

RESULTS

All patients were available after a median follow-up of 32 months (range 24-51). There were no significant differences in the mean CMS, Taft score and the ACJI between the two groups. The radiological assessment revealed no significant difference in the coracoclavicular distance. In both groups, a slight loss of reduction was observed. Periarticular ossification was seen in 11 patients of the minimally invasive AC joint repair and eight patients of the hook plate group but this did not affect the final outcome. Hook plates were removed after a median interval of 11.9 weeks (range 10-13).

CONCLUSION

Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation. However, in the hook plate group a second operation is mandatory for plate removal.

LEVEL OF EVIDENCE

III.

Secondary infection of haematoma following closed acromioclavicular joint dislocation

An unusual case of a patient presenting with a large infected haematoma following a traumatic grade II acromioclavicular joint dislocation is reported. Diagnosis of this rare complication, of an otherwise common self-limiting injury, was delayed until 19 days postinjury despite several presentations during this time with worsening swelling and pain. The patient was found to have significant tissue destruction by the time washout was performed and required multiple procedures to treat the infection. This case highlights the need for a high index of suspicion for complications, even following common self-limiting injuries, when patients represent with symptoms that do not fit the usual natural history of the condition, particularly if they have risk factors for bleeding and infection.

Reliability of radiographic measurements for acromioclavicular joint separations

INTRODUCTION

The treatment of acromioclavicular (AC) joint separations is controversial, particularly for Rockwood type III injuries. Rockwood type IV injuries, which correspond to horizontal instability, are very likely under-diagnosed. The objective of this study was to evaluate the inter- and intra-observer reproducibility of the Rockwood classification through an evaluation of standard radiographs, as described in the original article.

MATERIAL AND METHODS

This was a prospective radiographic study using protocol-based data from the 2014 symposium of the French Society of Arthroscopy (SFA). Fifteen anonymized radiological records were analysed by six independent examiners on two occasions, 1 week apart. The records consisted of a comparative A/P view of the two acromioclavicular joints (Zanca view), an axillary lateral view and dynamic lateral views (Tauber protocol) to uncover dynamic horizontal instability. A detailed analysis protocol was implemented that included absolute and relative measurements on each view; the relative measurements were used to account for radiographic magnification.

RESULTS

The inter- and intra-observer reproducibility on the A/P radiographs was good to excellent. The reproducibility was fair to good on the lateral views, but the measurements varied greatly from one subject to another, and significant errors were found with certain records. The reproducibility of the dynamic views proposed by Tauber was poor to fair.

DISCUSSION

Radiographic analysis of AC joint separations is reproducible in the vertical plane, which makes it possible to diagnose Rockwood type II, III and V injuries. On the other hand, static and dynamic analyses in the horizontal plane do not have good reproducibility and do not contribute to make an accurate diagnosis of Rockwood type IV injuries.

LEVEL OF EVIDENCE

Level I, Diagnostic study.

Arthroscopic fixation for acute acromioclavicular joint disruption using the TightRope device

PURPOSE

To review outcome after arthroscopic fixation for acute acromioclavicular (AC) joint dislocation using the TightRope device.

METHODS

Records of 15 men and 2 women aged 19 to 52 (mean, 35) years who underwent arthroscopic fixation using the TightRope device for acute (<3 weeks) AC joint dislocation of Rockwood type III (n=6), type IV (n=1), and type V (n=10) were reviewed. Outcome was evaluated using the Constant score. The coracoclavicular (CC) distance before and after surgery was compared.

RESULTS

The mean follow-up period was 22.1 (range, 12-37) months. The mean time to return to work was 4 (range, 1.5-12) months, excluding one failure. The mean postoperative Constant score was 86.4 (range, 63-96). The CC distance decreased from 21.5±5.2 mm preoperatively to 9.8±3.5 mm at 6 months and to 10±3.2 mm at one year. There was no over-correction. All patients had satisfactory outcome except for one who had rupture of the TightRope suture at 6 months. Two patients had partial loss of reduction (≥2 mm) after 3 to 6 months secondary to osteolysis at the clavicular button site.

CONCLUSION

Arthroscopic fixation using the TightRope device for acute AC joint dislocation achieves satisfactory outcome.

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.

POSTEROSUPERIOR SURGICAL ACCESS ROUTE FOR TREATMENT OF ACROMIOCLAVICULAR DISLOCATIONS: RESULTS FROM 84 SURGICAL CASES

OBJECTIVE

To evaluate the results from surgical treatment of 84 cases of acute acromioclavicular dislocation, using a posterosuperior access route.

METHODS

Eighty-four cases of acute acromioclavicular dislocation (grade III in the Allman-Tossy classification) operated between November 2002 and May 2010 were evaluated. The patients' mean age was 34 years. The diagnoses were made using clinical and radiographic evaluations. The patients were operated by the same surgical team, within three weeks of the date of the trauma, using a posterosuperior approach to the shoulder to access the top of the base of the coracoid process for placement of two anchors, which were used in reducing the dislocation. The minimum follow-up was 12 months. The postoperative clinical-radiographic evaluation was done using the modified Karlsson criteria and the University of California at Los Angeles (UCLA) score.

RESULTS

92.8% of the 84 patients treated presented good or excellent results, and 7.2% presented fair or poor results, using the UCLA assessment score. According to the modified Karlsson criteria, 76.2% were assessed as grade A, 17.9% as grade B and 5.9% as grade C.

CONCLUSION

The posterosuperior access route to the shoulder is a new option for accessing the coracoid process and treating acromioclavicular dislocation, with clinical and radiographic results equivalent to those in the literature.

Is AC TightRope fixation better than Bosworth screw fixation for minimally invasive operative treatment of Rockwood III AC joint injury?

INTRODUCTION

Injuries to the acromioclavicular (AC) joint are common in sports participants and may lead to instability or degenerative changes that require surgical intervention. Diagnostics include X-ray projections; MRI could also be a useful method. Surgical treatment of acute Rockwood type III AC dislocation varies on a case-by-case basis and includes coracoclavicular (CC) stabilisation with two techniques of minimal invasive fixation: the Bosworth screw and AC TightRope fixation (Arthrex, US). The aim of this study was to analyse whether there is a difference between these two surgical procedures in the quality of repair of CC ligaments by comparing preoperative and postoperative AC joint radiological and clinical findings.

PATIENTS AND METHODS

In this study, we evaluated our 5 years' experience of surgical management of Rockwood type III AC dislocation. Radiological analyses included measurement of CC distance at the AC joint, X-ray and MRI evaluation of CC ligament scar tissue continuity; clinical outcome was assessed using the Constant Murley, Oxford Shoulder and DASH scores preoperatively and during 6 months of postoperative follow-up.

RESULTS

A total of 68 patients with Rockwood type III AC dislocation were treated surgically with minimally invasive CC fixation using either the AC TightRope implant (34 patients, TR group) or the Bosworth screw (34 patients, BS group) in a prospective, randomised clinical trial. There was no statistically significant difference in radiological X-ray and MRI evaluations of postoperative results between the two groups of patients at the end of follow-up. Patients in the TR group reported significantly less inconvenience with treatment as the patients in the BS group had to undergo a second operation to remove the Bosworth screw. Postoperative recurrence of dislocation was observed in two patients in the TR group (5.88%) and in four patients in the BS group (11.76%) 6 months postoperatively. The difference between the two groups was not statistically significant (p=0.4).

CONCLUSION

MRI could be a useful method to evaluate quality of repair of CC ligaments. The minimally invasive surgical techniques used in this study showed similar radiological and clinical efficacy in the treatment of acute Rockwood type III AC dislocation, but AC TightRope fixation provided patients with significantly more treatment satisfaction and less inconvenience than Bosworth screw fixation.

Multicenter Randomized Clinical Trial of Nonoperative Versus Operative Treatment of Acute Acromio-Clavicular Joint Dislocation

OBJECTIVE

To perform a randomized clinical trial of operative versus nonoperative treatment of acute acromio-clavicular (AC) joint dislocations using modern surgical fixation and both patient-based and surgeon-based outcome measures to determine which treatment method was superior.

DESIGN

Prospective, randomized.

SETTING

Multicenter.

PATIENTS/PARTICIPANTS

Eight-three patients with acute (<28 days from the time of injury) complete (grade III, IV, and V) dislocations of the AC joint.

INTERVENTION

Patients were randomized to operative repair with hook plate fixation versus nonoperative treatment (operative repair, 40; nonoperative treatment, 43).

MAIN OUTCOME MEASUREMENTS

Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year after injury. Assessment also included a complete clinical assessment, evaluation of the constant score, and a radiographic evaluation at 6 weeks, and at 3, 6, 12, and 24 months.

RESULTS

There were no demographic differences between the 2 groups, and the mechanisms of injury were similar between the 2 groups. The DASH scores (a disability score, lower score is better) were significantly better in the nonoperative group at 6 weeks (operative, 45; nonoperative, 31; P = 0.014) and 3 months (operative, 29; nonoperative, 16; P = 0.005). There were no significant differences between the groups at 6 months (operative, 14; nonoperative, 12; P = 0.442), 1 year (operative, 9; nonoperative, 9; P = 0.997), or 2 years (operative, 5; nonoperative, 6; P = 0.439) after injury. Constant scores were similar (better scores in the nonoperative group at 6 weeks, 3 months, and 6 months; P = 0.0001; and no difference thereafter). Although radiographic results were better in the operative group, the reoperation rate was significantly lower in the nonoperative group (P < 0.05).

CONCLUSIONS

Although hook plate fixation resulted in superior radiographic alignment, it was not clinically superior to nonoperative treatment of acute complete dislocations of the AC joint. The nonoperative group had better early scores, although both groups improved from a significant level of initial disability to a good or excellent result (mean DASH score, 5-6; mean constant score, 91-95) at 2 years. At present, there is no clear evidence that operative treatment with the currently available hook plate improves short-term outcome for complete AC joint dislocations.

Outcome After Arthroscopic Reconstruction of the Coracoclavicular Ligaments Using a Double-Bundle Coracoid Cerclage Technique

PURPOSE

We report the outcome of an arthroscopic technique for coracoclavicular ligament reconstruction using an anatomic coracoid cerclage.

METHODS

Between March 2011 and September 2012, 12 consecutive patients with symptomatic chronic (>4 weeks from injury) type V acromioclavicular separation for which nonoperative treatment failed were treated with arthroscopic double-bundle reconstruction of the coracoclavicular ligaments using tendon allograft by the first author. The clinical records, operative reports, and preoperative and follow-up radiographs were reviewed. The visual analog scale score, Subjective Shoulder Value, Simple Shoulder Test score, and Constant-Murley score were evaluated preoperatively and at each follow-up appointment.

RESULTS

The study included 12 shoulders in 12 young active-duty soldiers with symptomatic high-grade acromioclavicular separation who were treated with a technique for arthroscopic reconstruction of the coracoclavicular ligaments. The mean age was 25 years (range, 20 to 35 years). The injury occurred during sports activity in 11 patients. One patient was injured in a motorcycle accident. The mean time from injury to surgery was 17.8 months (range, 1.5 to 72 months). The minimum length of follow-up was 24 months (mean, 30.4 months; range, 24 to 42 months). The mean preoperative and postoperative outcome scores were significantly different (P < .0001) for all subjective outcome measures. The mean Constant-Murley score improved from 58.4 (range, 51 to 76) to 96 (range, 88 to 100). The mean visual analog scale score improved from 8.1 (range, 7 to 10) to 0.58 (range, 0 to 2). The mean Subjective Shoulder Value improved from 32.9% (range, 10% to 70%) to 95% (range, 80% to 100%). The mean Simple Shoulder Test score improved from 6 (range, 5 to 8) to 11.83 (range, 11 to 12). All patients returned to their normal preinjury level of activity by 6 months. Radiographs at last follow-up showed no loss of reduction with maintenance of the coracoclavicular interval. There was 1 complication (8.5%), a postoperative superficial wound infection, that was treated accordingly.

CONCLUSIONS

We present an arthroscopic technique for double-bundle tendon graft reconstruction of the coracoclavicular ligaments using the coracoid cerclage technique. This method showed good outcomes and maintenance of radiographic reduction with high patient satisfaction and a low complication rate.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Acromioclavicular dislocation: treatment and rehabilitation. Current perspectives and trends among Brazilian orthopedists

Objective

To evaluate the approaches and procedures used by Brazilian orthopedic surgeons in treatment and rehabilitation of acromioclavicular dislocation of the shoulder.

Methods

A questionnaire comprising eight closed questions that addressed topics relating to treatment and rehabilitation of acromioclavicular dislocation was applied to Brazilian orthopedic surgeons over the three days of the 45th Brazilian Congress of Orthopedics and Traumatology, in 2013.

Results

A total of 122 surgeons completely filled out the questionnaire and formed part of the sample analyzed. Most of them came from the southeastern region of the country. In this sample, 67% of the participants would choose surgical treatment for patients with grade 3 acromioclavicular dislocation. Regarding the preferred technique for surgical treatment of acute acromioclavicular dislocation, a majority of the surgeons used subcoracoid ligature with acromioclavicular fixation and transfer of the coracoacromial ligament (25.4%). Regarding complications found after surgery had been performed, 43.4% and 32.8% of the participants, respectively, stated that residual deformity of the operated joint and pain were the complications most seen during the postoperative period.

Conclusions

Although there was no consensus regarding the treatment and rehabilitation of acromioclavicular dislocation, evolution had occurred in some of the topics analyzed in this questionnaire applied to Brazilian orthopedists. However, further controlled prospective studies are needed in order to evaluate the clinical and scientific benefit of these trends.

Stabilisation for the disrupted acromioclavicular joint using a braided polyester prosthetic ligament

PURPOSE

To report outcomes of 21 men who underwent stabilisation for the disrupted acromioclavicular joint (ACJ) using a braided polyester prosthetic ligament.

METHODS

21 men aged 23 to 76 (mean, 43) years underwent stabilisation for the disrupted ACJ of Rockwood type 3 (n=12), type 4 (n=1), and type 5 (n=8) using a braided polyester prosthetic ligament.

RESULTS

The mean time from injury to surgery was 6.8 (range, 0-19) months. The mean follow-up duration was 30 (range, 7-67) months. The mean Constant Score was 86.8 (range, 62-100), and the mean individualised Constant Score was 88.5 (range, 68-100). The mean Oxford Shoulder Score was 43.1 (range, 28-48). The mean abduction power of the operated side was 82% (range, 31%-97%) that of the normal side. 20 patients were satisfied with the procedure. One patient was dissatisfied who developed scapulothoracic bursitis. One patient required arthroscopic subacromial decompression for impingement. One patient sustained a redislocation following a fall at 6 weeks and declined further surgery.

CONCLUSION

The braided polyester prosthetic ligament achieved good outcome for patients undergoing stabilisation for the disrupted ACJ.

Anatomical Double-Bundle Coracoclavicular Reconstruction in Chronic Acromioclavicular Dislocation

The purpose of this study was to evaluate the clinical and radiological outcomes of anatomical double-bundle coracoclavicular (CC) reconstruction using the coracoacromial (CA) ligament and the conjoined tendon for the treatment of chronic acromioclavicular (AC) joint dislocation. A retrospective evaluation was performed on 18 patients who underwent an anatomical CC reconstruction using the CA ligament and the conjoined tendon for chronic AC joint dislocation. Patients were treated surgically between April 2007 and January 2012. Mean follow-up was 35.3 months (range, 24-49 months). All patients were evaluated for functional outcomes using the modified University of California, Los Angeles (UCLA) shoulder rating scale for chronic AC injury and the Constant-Murley shoulder outcome score. Range of motion and shoulder and elbow strength were also measured. Plain radiographs were taken to evaluate reduction status and CC distance. Mean modified UCLA shoulder rating scale at final follow-up was 18.1 points (range, 13-20 points). No significant difference in mean Constant-Murley scores existed between the injured and contralateral shoulders (P=.26). At final follow-up, 15 (83.3%) patients had well-maintained reduction and 2 (11.1%) patients had a partial loss of reduction. One other patient had a complete loss of reduction due to a postoperative fall. The CC distance was not significantly different between the injured and contralateral shoulders in the immediate postoperative period (P=.46) or at final follow-up (P=.14). One superficial wound infection occurred and was treated with routine wound care. An anatomical double-bundle CC reconstruction using the CA ligament and the conjoined tendon for the treatment of chronic AC joint dislocation is a reliable surgical method with good results.

Vascular graft employment in the surgical treatment of acute and chronic acromio-clavicular dislocation

OBJECTIVES

To show the efficiency and safety of a surgical treatment in both acute and chronic acromio-clavicular junction (ACJ) dislocations.

DESIGN

Retrospective.

SETTING

Department of Orthopedics and Traumatology at IRCCS San Raffaele Hospital.

PATIENTS/PARTICIPANTS

This study was performed on 37 subjects classified as Rockwood grade III-V or Tossy III ACJ dislocation.

PROCEDURE

The surgical treatment was carried out by placing a vascular graft (GorePropaten(®)) between the tip of the coracoid process and the mid-lateral side of the clavicle with two temporary percutaneous K-wires positioned in a parallel manner in the AC ligament through the acromion and clavicle for 30 days to improve stability.

MAIN OUTCOME MEASUREMENTS

Outcomes were assessed using the Constant Shoulder (CS) score, DASH score, subjective satisfaction, and stability of AC joint at 24 months. UCLA scores taken preoperatively and at 15-month follow-up were used to perform statistical analysis significance using a control group treated conservatively. Postoperative X-rays were examined to assess joint stability after 24 months.

RESULTS

Preoperative CS score was 51 ± 12 in the acute group and 55 ± 15 in the chronic group. Follow-up mean CS score was 88 ± 11 in the acute group and 82 ± 20 in the chronic group at 24 months. Preoperative DASH score was 19 ± 3 in the acute group and 14 ± 5 in the chronic group. Mean DASH score was 3.60 ± 7 in the acute group and 6.42 ± 6 in the chronic group. Preoperative UCLA scores were 14.6 ± 2 and 15 ± 7 in the acute group and chronic group, respectively. At 15-month follow-up, UCLA scores of 28.1 ± 1.9 and 27.7 ± 1 in the acute and chronic group, respectively, showed a significant improvement (p < 0.05) compared with UCLA scores taken preoperatively and at 15 months in the control group treated conservatively of 15.8 ± 0.9 and 16.2 ± 0.9, respectively. Results were good to excellent in 10 patients from the acute group and 23 patients from the chronic group who presented clinical stability of the AC joint without pain. Postoperative radiography showed anatomical repositioning of the ACJ and joint stability in 35 cases, but only two patients showed a partial re-dislocation at the 24-month X-ray follow-up. No infections, either deep or superficial, or nerve palsies were reported.

CONCLUSIONS

Given the results obtained during the study and the response of the patients in both acute and chronic groups, the authors found that the employment of a vascular graft combined with temporary percutaneous K-wires is able to improve the patient's clinical outcome following an acromio-clavicular joint dislocation.

Minimally Invasive Coracoclavicular Ligament Reconstruction With a Flip-Button Technique (MINAR): Clinical and Radiological Midterm Results

BACKGROUND

Acromioclavicular (AC) joint dislocation is a frequent injury in sports.

HYPOTHESIS

A minimally invasive flip-button technique, MINAR (minimally invasive acromioclavicular joint reconstruction), will achieve good clinical and radiographic results in the surgical treatment of high-grade AC joint dislocations.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

In this study, 96 patients with AC joint dislocation grades III through V and minimally invasive flip-button repair were identified. Radiographic assessment was performed by use of the Alexander view and by anteroposterior stress radiograph. Clinical outcomes were assessed with the Constant and Taft scores. Factors that influenced outcomes, such as age, time from trauma to surgery, and degree of dislocation, were evaluated.

RESULTS

Of the 96 patients, 83 (86.4%; 3 women and 80 men) were able to participate in clinical and radiographic follow-up. The average age of the participants was 39 years (range, 17-80 years). At a mean follow-up of 39 months (range, 12-78 months), clinical assessment revealed excellent results with a mean Constant score of 94.7 (range, 61-100). Clinical and radiological assessment using the Taft score also showed excellent results, with a mean score of 10.8 (range, 3-12). The mean time period from trauma to surgery was 6 days (range, 0-22 days), and mean duration of surgery was 48 minutes (range, 24-98 minutes). Nine patients (10.8%) underwent revision surgery due to recurrent dislocation (n = 8) or wound infection (n = 1). Radiological assessment showed that 18 patients had sustained a loss of reduction defined as subluxation of 50% of the clavicle shaft width in the vertical plane. However, there was no significant correlation (P = .254) with clinical outcome. Patient age was a relevant factor influencing outcome, as significantly higher outcome values were detected for younger patients (P = .024). No significant influence was shown for the time period from trauma to surgery (P = .336) or degree of dislocation after trauma (P = .987).

CONCLUSION

The MINAR technique is a safe procedure and achieves good to excellent clinical and radiographic results in the surgical treatment of high-grade AC joint dislocations. Despite the simplicity of this technique, the surgeon has to overcome the learning curve to minimize the risk of recurrent dislocation.

Current state of treatment of acute acromioclavicular joint injuries in Germany: is there a difference between specialists and non-specialists? A survey of German trauma and orthopaedic departments

PURPOSE

The purpose of this study was to evaluate currently preferred treatment strategies as well as the acceptance of new arthroscopic techniques among German orthopaedic surgeons. We assumed that surgeons specialized in shoulder surgery and arthroscopy would treat acute acromioclavicular joint dislocations different to non-specialized surgeons.

METHODS

Seven hundred and ninety-six orthopaedic and/or trauma departments were found through the German hospital directory of 2012. Corresponding websites were searched for the email address of the chair of shoulder surgery (if applicable) or the department. Seven hundred forty-six emails with the request for study participation including a link to an online survey of 36 questions were sent. In 60 emails, the recipient was unknown.

RESULTS

Two hundred and three (30 %) surgeons participated in the survey. one hundred and one were members of the AGA (German-speaking Society for Arthroscopy and Joint-Surgery) and/or of the DVSE (German Association of Shoulder and Elbow Surgery) and regarded as specialists, while 102 were non-members and regarded as non-specialists. According to the treatment of Rockwood I/II and IV-VI injuries, no significant differences were found. Seventy-four % of non-specialists and 67 % of specialists preferred surgical treatment for Rockwood III injuries (P = 0.046). Non-specialists would use the hook plate in 56 % followed by the TightRope in 16 %; specialists would use the TightRope in 38 % followed by the hook plate in 32 % (P = 0.004).

CONCLUSIONS

The majority of German orthopaedic and trauma surgeons advise surgical treatment for Rockwood III injuries. Specialists recommend surgery less often. Non-specialists prefer the hook plate, whereas specialists prefer the arthroscopic TightRope technique.

LEVEL OF EVIDENCE

Observational survey, Level IV.

Comparison of results between hook plate fixation and ligament reconstruction for acute unstable acromioclavicular joint dislocation

Background

In the present study, we aimed to compare clinical and radiographic outcomes between hook plate fixation and coracoclavicular (CC) ligament reconstruction for the treatment of acute unstable acromioclavicular (AC) joint dislocation.

Methods

Forty-two patients who underwent surgery for an unstable acute dislocation of the AC joint were included. We divided them into two groups according to the treatment modality: internal fixation with a hook plate (group I, 24 cases) or CC ligament reconstruction (group II, 18 cases). We evaluated the clinical outcomes using a visual analog scale (VAS) for pain and Constant-Murley score, and assessed the radiographic outcomes based on the reduction and loss of CC distance on preoperative, postoperative, and final follow-up plain radiographs.

Results

The mean VAS scores at the final follow-up were 1.6 ± 1.5 and 1.3 ± 1.3 in groups I and II, respectively, which were not significantly different. The mean Constant-Murley scores were 90.2 ± 9.9 and 89.2 ± 3.5 in groups I and II, respectively, which were also not significantly different. The AC joints were well reduced in both groups, whereas CC distance improved from a mean of 215.7% ± 50.9% preoperatively to 106.1% ± 10.2% at the final follow-up in group I, and from 239.9% ± 59.2% preoperatively to 133.6% ± 36.7% at the final follow-up in group II. The improvement in group I was significantly superior to that in group II (p < 0.001). Furthermore, subluxation was not observed in any case in group I, but was noted in six cases (33%) in group II. Erosions of the acromion undersurface were observed in 9 cases in group I.

Conclusions

In cases of acute unstable AC joint dislocation, hook plate fixation and CC ligament reconstruction yield comparable satisfactory clinical outcomes. However, radiographic outcomes based on the maintenance of reduction indicate that hook plate fixation is a better treatment option.

Acromioclavicular third degree dislocation: surgical treatment in acute cases

Background

The management of acute Rockwood type III acromioclavicular joint (ACJ) dislocation remains controversial, and the debate about whether patients should be conservatively or surgically treated continues. This study aims to compare conservative and surgical treatment of acute type III ACJ injuries in active sport participants (<35 years of age) by analysing clinical and radiological results after a minimum of 24 months follow-up.

Methods

The records of 72 patients with acute type III ACJ dislocations who were treated from January 2006 to December 2011 were retrospectively evaluated. Patients were categorised into two groups. group A included 25 patients treated conservatively, and group B included 30 patients treated surgically with the TightRope™ system. Seventeen patients were lost to follow-up.

All patients were evaluated at final follow-up with these clinical scores: Constant, University of California Los Angeles scale (UCLA), American Shoulder and Elbow Surgeons Scale (ASES) and Acromioclavicular Joint Instability (ACJI) and with a subjective evaluation of the patient satisfaction, aesthetic results and shoulder function. The distance between the acromion and clavicle and between the coracoid process and clavicle were evaluated radiographically and compared with preoperative values. Δ, the difference in mm between the distance at the final follow-up and at T0 in the injured shoulder, and α, the side-to-side difference in mm at follow-up, were calculated. Heterotopic ossification and postoperative osteolysis were evaluated in both groups.

Results

There were no major intraoperative complications in the surgical group. The subjective parameters significantly differed between the two groups. Constant, ASES and UCLA scores were similar in both groups (P > 0.05), whereas ACJI results favoured the surgical group (group A, 72.4; group B, 87.9; P < 0.05). All measurements of radiographic evaluation were significantly reduced in the surgical group compared with the conservative group. In group A, we detected calcifications in 30% of patients; in group B we detected two cases of moderate osteolysis and calcifications in 70% of patients.

Conclusion

Although better subjective and radiographic results were achieved in surgically treated patients, traditional objective scores did not show significant differences between the two groups. Our results cannot support routine use of surgery to treat type III ACJ dislocations.

Management of acromioclavicular joint injuries

Although recent advances have been made in the treatment of acromioclavicular (AC) joint injuries, they are still challenging for shoulder surgeons. There is a consensus that type I and II injuries should be treated nonoperatively, whereas acute type IV, V, and VI injuries should be treated surgically. There is no algorithm for correctly diagnosing and treating type III injuries, but the current trend is toward nonoperative treatment except for those with persistent symptoms and functional limitations after a course of conservative management. If surgery is indicated, newer anatomic techniques of reconstructing the coracoclavicular (CC) and AC ligaments are recommended.

Results of Operative and Nonoperative Treatment of Rockwood Types III and V Acromioclavicular Joint Dislocation: A Prospective, Randomized Trial With an 18- to 20-Year Follow-up

Background:

The optimal treatment of acute, complete dislocation of the acromioclavicular joint (ACJ) is still unresolved.

Purpose:

To determine the difference between operative and nonoperative treatment in acute Rockwood types III and V ACJ dislocation.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

In the operative treatment group, the ACJ was reduced and fixed with 2 transarticular Kirschner wires and ACJ ligament suturing. The Kirschner wires were extracted after 6 weeks. Nonoperatively treated patients received a reduction splint for 4 weeks. At the 18- to 20-year follow-up, the Constant, University of California at Los Angeles Shoulder Rating Scale (UCLA), Larsen, and Simple Shoulder Test (SST) scores were obtained, and clinical and radiographic examinations of both shoulders were performed.

Results:

Twenty-five of 35 potential patients were examined at the 18- to 20-year follow-up. There were 11 patients with Rockwood type III and 14 with type V dislocations. Delayed surgical treatment for ACJ was used in 2 patients during follow-up: 1 in the operatively treated group and 1 in the nonoperatively treated group. Clinically, ACJs were statistically significantly less prominent or unstable in the operative group than in the nonoperative group (normal/prominent/unstable: 9/4/3 and 0/6/3, respectively; P = .02) and in the operative type III (P = .03) but not type V dislocation groups. In operatively and nonoperatively treated patients, the mean Constant scores were 83 and 85, UCLA scores 25 and 27, Larsen scores 11 and 11, and SST scores 11 and 12 at follow-up, respectively. There were no statistically significant differences in type III and type V dislocations. In the radiographic analysis, the ACJ was wider in the nonoperative than the operative group (8.3 vs 3.4 mm; P = .004), and in the type V dislocations (nonoperative vs operative: 8.5 vs 2.4 mm; P = .007). There was no statistically significant difference between study groups in the elevation of the lateral end of the clavicle. Both groups showed equal levels of radiologic signs of ACJ osteoarthritis and calcification of the coracoclavicular ligaments.

Conclusion:

Nonoperative treatment was shown to produce more prominent or unstable and radiographically wider ACJs than was operative treatment, but clinical results were equally good in the study groups at 18- to 20-year follow-up. Both treatment methods showed statistically significant radiographic elevations of the lateral clavicle when compared with a noninjured ACJ.

Comparison of single and two-tunnel techniques during open treatment of acromioclavicular joint disruption

BACKGROUND

Coracoclavicular (CC) ligament reconstruction with semitendinosus tendon (ST) grafts has become more popular and has achieved relatively good results; however optimal reconstruction technique, single-tunnel or two-tunnel, still remains controversial. This paper is to compare the clinical and radiographic data of allogenous ST grafting with single- or two-tunnel reconstruction techniques of the AC joint.

METHODS

The outcomes of 21 consecutive patients who underwent anatomical reduction and ST grafting for AC joint separation were reviewed retrospectively. Patients were divided into two groups: single-tunnel group (11) and two-tunnel group (10). All patients were evaluated clinically and radiographically using a modified UCLA rating scale.

RESULTS

The majority of separations (18 of 21) were Rockwood type V, with one each in type III, IV and VI categories. The overall mean follow-up time was 16 months, and at the time of the latest follow-up, the overall mean UCLA rating score was 14.1 (range 8-20).The percentage of good-to-excellent outcomes was significantly higher for patients with the two-tunnel technique than for those with the one-tunnel technique (70% vs. 18%, respectively, p = 0.03). Within the single-tunnel group, there was no statistically significant difference in percentage of good-to-excellent outcomes between patients with vs. without tightrope augmentation (17% vs 20%, p > 0.99). Similarly, within the two-tunnel group, there was no significant difference in the percentage of good-to-excellent outcomes between the graft only and augment groups (67% vs. 75%, p > 0.99).

CONCLUSION

Anatomical reduction of the AC joint and reconstruction CC ligaments are crucial for optimal joint stability and function. Two-tunnel CC reconstruction with an allogenous ST graft provides superior significantly better radiographic and clinical results compared to the single-tunnel reconstruction technique.

Surgical treatment of chronic acromioclavicular joint dislocation with autogenous tendon grafts

Background

Conservative treatment of acromioclavicular (AC) joint dislocation is not always successful. A consequence of persistent AC joint dislocation may be chronic pain and discomfort in the shoulder region as well a sensation of constant AC joint instability and impaired shoulder function. Stabilization of the AC joint may reduce these sequels.

Materials and methods

Due to chronic AC joint dislocation, 39 patients in our hospital underwent coracoclavicular (CC) ligament reconstruction with autogenous semitendinosus and gracilis tendons between May 2005 and April 2011. We examined 25 patients after a mean of 4.2 years. The outcomes were Constant shoulder Score (CS), Disabilities of the Arm, Shoulder and Hand (DASH), pain (Visual Analog Scale, VAS), cross-arm test, stability of the AC joint, and complications. The follow-up visits included anteroposterior and axillary radiographs.

Results

Mean CS was 83 in the injured shoulder and 91 in the uninjured shoulder (p = 0.002). Mean DASH was 14. In 14 patients, the AC joint was clinically stable; pain was minor. In radiographs, osteolysis of the lateral clavicle and tunnel widening were markedly common. Fracture of the coracoid process occurred in 5 patients, and 3 suffered a fracture of the clavicle; 2 had a postoperative infection.

Conclusions

Anatomic reconstruction of CC ligaments showed a moderate subjective outcome at the 4-year follow-up. After surgery, almost half the AC joints failed to stabilize. Lateral clavicle osteolysis and tunnel widening were notably common complications.

Controversies relating to the management of acromioclavicular joint dislocations

The aim of this review is to address controversies in the management of dislocations of the acromioclavicular joint. Current evidence suggests that operative rather than non-operative treatment of Rockwood grade III dislocations results in better cosmetic and radiological results, similar functional outcomes and longer time off work. Early surgery results in better functional and radiological outcomes with a reduced risk of infection and loss of reduction compared with delayed surgery. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Although non-controlled studies report promising results for arthroscopic coracoclavicular fixation, there are no comparative studies with open techniques to draw conclusions about the best surgical approach. Non-rigid coracoclavicular fixation with tendon graft or synthetic materials, or rigid acromioclavicular fixation with a hook plate, is preferable to fixation with coracoclavicular screws owing to significant risks of loosening and breakage. The evidence, although limited, also suggests that anatomical ligament reconstruction with autograft or certain synthetic grafts may have better outcomes than non-anatomical transfer of the coracoacromial ligament. It has been suggested that this is due to better restoration horizontal and vertical stability of the joint. Despite the large number of recently published studies, there remains a lack of high-quality evidence, making it difficult to draw firm conclusions regarding these controversial issues.

Acromioclavicular joint fixation using an acroplate combined with a coracoclavicular screw

Background

Appropriate treatment of acromioclavicular joint dislocation is controversial. Acroplate fixation is one of the most common treatment methods of acromioclavicular joint (ACJ) dislocation. Based on the risk of re-dislocation after Acroplate fixation, we assumed that combined fixation with an Acroplate and a coracoclavicular screw helps improve the outcome.

Objectives

The main purpose of the current study was to compare the outcome of ACJ dislocation treated with an Acroplate alone and in combination with coracoclavicular screw.

Patients and Methods

This study was carried out on 40 patients with ACJ dislocation types III to VI who were divided randomly into two equal groups: Acroplate group (P) and Acroplate in combination with coracoclavicular screw group (P + S). The screws were extracted 3-6 months postoperatively. The patients were followed for 1 year and Imatani’s score was calculated. Finally, the data were compared between the groups.

Results

The mean Imatani’s score was significantly higher in P + S group (83.4 ± 14.1) than P group (81.2 ± 10.3) (P < 0.001). The mean duration of surgery was the same in the two groups (59.8 ± 9.4 minutes in group P V.s 64.3 ± 10.9 minutes in group P + S; P = 0.169). There were no cases of re-dislocation, degenerative changes and ossification and all patients returned to their previous jobs or sporting activities.

Conclusions

Using a coracoclavicular screw combined with an Acroplate can improve the patients’ function after ACJ disruption without any significant increase in surgical duration. Authors recommend this technique in the fixation of ACJ dislocation.

Defining the terms acute and chronic in orthopaedic sports injuries: a systematic review

BACKGROUND

Although many authors report on acute injuries and chronic injuries in the orthopaedic literature, the actual terms are seldom explicitly defined.

HYPOTHESIS

Much of the literature pertaining to sports injuries that are acute or chronic does not define these terms. It is believed that definitions will provide clarity and specificity in future literature.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of 116 articles was conducted to determine whether and how the terms acute and chronic were defined as they pertain to several commonly treated conditions: Achilles tendon rupture, distal biceps tendon rupture, pectoralis major tendon rupture, anterior cruciate ligament (ACL) tear, anterior shoulder instability, and acromioclavicular (AC) joint dislocation. Articles were isolated from various databases and search engines by use of keywords to identify relevant literature.

RESULTS

This study determined that the terms acute and chronic for each injury are defined, respectively, as follows: Achilles tendon rupture: <1 week, >4 weeks; distal biceps tendon rupture: <6 weeks, >12 weeks; pectoralis major tendon rupture: <6 weeks, >6 weeks; ACL tear: <6 weeks, >6 months; anterior shoulder instability: <2 weeks, >6 months; AC joint dislocation, <3 weeks, >6 weeks.

CONCLUSION

The current literature varies greatly in defining the terms acute and chronic in common sports injuries. The vast majority of authors imply these terms, based on the method of their studies, rather than define them explicitly. Injuries involving tendons showed greater consistency among authors, thus making a definition based on consensus easier to derive. The literature on ACL and shoulder instability in particular showed great variability in defining these terms, likely representing the more complex nature of these injuries and the fact that timing of surgery in the majority of patients does not particularly affect the complexity of the surgical approach and treatment.

CLINICAL RELEVANCE

Defining injuries as acute or chronic is clinically relevant in many cases, particularly concerning tendon injuries, where these terms have implications regarding the anatomic pathologic changes and tissue quality, which may necessitate augmentation and alter the initial surgical plan. In cases where these terms are less pertinent to operative treatment considerations, they bring clarity to the discussion of the acuity of the injury (as it pertains to time from insult).

Clinical and radiographical results after double flip button stabilization of acute grade III and IV acromioclavicular joint separations

INTRODUCTION

Persistent horizontal instability after acute acromioclavicular (AC) joint separation may provoke unsatisfactory results of conservative treatment.

HYPOTHESIS

the arthroscopically assisted double flip button stabilization of acute horizontally unstable grade III and IV AC joint disruptions results in full functional restoration and stable radiological reposition.

MATERIALS

21 patients treated for an acute grade III or IV AC joint separation were enrolled. Clinical assessment at least 2-year postoperative included the constant score (CS) and the simple shoulder test. A panorama stress view, bilateral axial view and an AC view were obtained for radiographic evaluation.

RESULTS

19 individuals (mean 37 years; 17 men) with 16 Rockwood type III and 3 type IV injuries were available for examination 24–51 months postoperatively. The mean CS was 90.2 points (SD 6.5) with no statistically significant difference between CS and age-adjusted normative values. The mean Simple Shoulder Test scored 11.5 points (range 8–12). Loss of reduction of more than 2 mm in the coronal plane stress views was present in 6 patients (32 %) with no associated loss of functional outcome. Two of four reported complications in four patients were treated surgically (one open revision with graft augmentation for coracoid implant break out, one arthroscopic capsular release for persistent glenohumeral stiffness).

CONCLUSION

Arthroscopically assisted double flip button stabilization for acute grade III and IV AC joint separation restores fully horizontal stability and age-expected shoulder function, resulting in high patient satisfaction, despite a loss of reduction observed radiographically in approximately one-third of patients.

LEVEL OF EVIDENCE

IV.

Complications after anatomic fixation and reconstruction of the coracoclavicular ligaments

BACKGROUND

Reconstruction of the disrupted acromioclavicular (AC) joint has historically resulted in high complication rates. As a result, there has been a move toward anatomic coracoclavicular (CC) ligament fixation and reconstruction, owing to its numerous biomechanical advantages and perceived clinical advantages.

PURPOSE

To report and analyze the unique complications associated with these anatomic CC ligament procedures using either cortical fixation buttons (CFBs) or tendon grafts (TGs) and to evaluate the effect that these complications have on patient outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From January 2006 until May 2011, a total of 59 primary anatomic CC ligament procedures were performed using either CFBs or TGs. Demographic, surgical, subjective (including the American Shoulder and Elbow Surgeons [ASES], quick Disabilities of the Arm, Shoulder and Hand [QuickDASH], Short Form-12 [SF-12], and Single Assessment Numeric Evaluation [SANE] scores), and radiographic data along with surgical complications were prospectively collected and retrospectively analyzed. Construct survivorship, defined as the maintenance of reduction of the AC joint, was calculated using the Kaplan-Meier method at 12- and 24-month intervals.

RESULTS

Surgical treatment for AC joint dislocations was performed in 3 women (4 shoulders) and 52 men (55 shoulders) with a mean age of 43.6 years (range, 18-71 years); 13 shoulders (22.0%) underwent fixation using the CFB technique, and 46 shoulders (78.0%) underwent reconstruction using the TG technique. The overall complication rate was 27.1% (16/59) in this study. There were 3 complications (23.1%) in the CFB group, including 1 coracoid fracture and 2 cases of hardware failure resulting in a loss of reduction. There were 13 complications (28.2%) in the TG group, including 4 graft ruptures, 2 clavicle fractures, 1 case of hardware failure, 1 hypertrophic distal clavicle, 2 cases of hardware pain, 1 suture granuloma, 1 case of adhesive capsulitis, and 1 case of axillary neuropathy. Twelve- and 24-month construct survivorship was calculated to be 86.2% and 83.2%, respectively. Of the 43 shoulders that did not have a complication, mean ASES scores significantly improved from 57.5 (range, 0-97) to 91 (range, 63-100) (P < .001), and mean SF-12 physical component summary scores significantly improved from 45 (range, 25-58) to 56 (range, 43-65.8) (P < .001) after a mean 2.4-year follow-up (range, 1.0-5.7 years). There were no significant differences in outcomes between those that did and did not experience a complication, with the exception that those with complications had significantly decreased median patient satisfaction compared with those without complications (3.5 vs 9, respectively; P = .049).

CONCLUSION

Anatomic procedures to treat disrupted CC ligaments using either CFBs or TGs resulted in an overall complication rate of 27.1% (16/59). Construct survivorship was calculated to be 86.2% at 12 months and 83.2% at 24 months. Good to excellent outcomes could only be reported in those patients who did not have a complication.

Surgical treatment of chronic acromioclavicular dislocation with biologic graft vs synthetic ligament: a prospective randomized comparative study

BACKGROUND

Acromioclavicular (AC) dislocation involves complete loss of articular contact; it is defined as chronic when it follows conservative management or unsuccessful surgical treatment.

MATERIALS AND METHODS

The study compared the clinical and radiographic outcomes of AC joint stabilization performed in 40 patients with chronic dislocation using a biological allograft (group A) or a synthetic ligament (group B). Demographic data included: M/F: 25/15; mean age: 35 ± 3.2 years; previous surgery in 11 patients, including Weaver-Dunn (3), coracoacromial ligament repair (4), stabilization with K-wires (4). Dislocation was type III in 14 (35 %) and type IV in 26 (65 %) patients. Clinical assessment was with the Constant-Murley score (pre- and postoperative) and with the modified UCLA score. Enrollment started in January 2004 and was completed in March 2008. Patients were evaluated at 1 and 4 years. Postoperative X-rays were examined to assess joint stability in the coronal and axial planes, coracoclavicular ossification, and signs of AC joint osteoarthritis and distal clavicular osteolysis.

RESULTS

The "biological" group achieved significantly better clinical scores than the "synthetic" group at both 1 and 4 years. Poor subjective satisfaction and lower clinical scores were found in the 3 patients (1 from group A and 2 from group B) who experienced complete postoperative dislocation. No significant correlations were found with other radiographic parameters.

CONCLUSIONS

The biological graft afforded better clinical and radiographic outcomes than the synthetic ligament in patients with chronic AC joint instability. Fixation to the clavicle constitutes the main weakness of both approaches and needs improving.

[Instability pattern of acromioclavicular joint dislocations type Rockwood III: relevance of horizontal instability]

BACKGROUND

There is no evidence-based treatment algorithm established for acromioclavicular joint (AC joint) dislocation classified as type Rockwood III injury. Recent meta-analyses revealed no advantage of surgical treatment compared to the non-operative approach. Both surgical and non-surgical approaches have been reported with inconsistent results. Therefore, the hypothesis of the current study was that patients classified as having Rockwood grade III injury may have different degrees of horizontal AC joint instability.

MATERIAL AND METHODS

A total of 18 consecutive patients who had sustained a dislocation of the AC joint classified as Rockwood III were evaluated radiologically to quantify the horizontal instability of the AC joint. The specific radiological investigation included lateral stress x-rays (Alexander view) und axial stress x-rays with the affected arm in a horizontal adduction position.

RESULTS

The dynamic horizontal instability of the AC joint was found to be independent of the vertical dislocation measured in the Rockwood classification.

CONCLUSION

For further treatment studies Rockwood III injuries should be distinguished in patients presenting with or without a substantial horizontal AC joint instability.

Operative or conservative treatment in patients with Rockwood type III acromioclavicular dislocation: a systematic review and update of current literature

PURPOSE

Despite previous studies the management of Rockwood type III acromioclavicular (AC) dislocations remains controversial and the debate continues about whether patients with Rockwood type III AC injuries should be treated conservatively or operatively. In this study, we will review the current literature and present an overview of the outcome of conservative versus operative treatment of Rockwood type III dislocations.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was used to conduct this review. A systematic search was performed in the Pubmed, Cochrane library, Embase, Scopus and Cumulative Index to Nursing and Allied Health Literature databases. Titles and abstracts were screened using predefined criteria and articles were critically appraised on relevance and validity.

RESULTS

After critical appraisal eight articles were included in the study. The objective and subjective shoulder function outcome was better in the operative group, especially in young adults, though the rate of complications and radiographic abnormalities were higher. The rehabilitation time was shorter in the conservative group, however the cosmetic outcome was worse.

CONCLUSIONS

This review showed no conclusive evidence for the treatment of Rockwood type III AC dislocations. Overall, physically active young adults seem to have a slight advantage in outcome when treated operatively.

Management of acute acromioclavicular joint dislocations: current concepts

Acromioclavicular joint (ACJ) injuries represent a common injury to the shoulder girdle. In the management algorithm of acute ACJ injuries complete radiological evaluation represents the key to a successful therapy. According to the classification of Rockwood the presence of a horizontal component in addition to vertical instability has to be detected. Using axillary functional views or Alexander views dynamic horizontal ACJ instability can be diagnosed in a simple, efficient and cost-effective manner reducing the number of mis-/underdiagnosed ACJ injuries. MRI should not be the imaging modality of first choice. The treatment of ACJ dislocations must consider two aspects. In addition to the correct type of injury therapy strategies should be adapted to patient's demands and compliance. Low grade AC injuries types I and II are treated non-operatively in terms of "skilful-neglect". High-grade injuries types IV-VI should be treated operatively within a time frame of 2-3 weeks after injury. A certain debate is still ongoing regarding type III injuries. Out from the literature, non-operative treatment of type III injuries results to provide at least equal functional outcomes as compared to surgical treatment associated with less complications and earlier return to professional and sports activities. If surgical treatment is indicated, open surgical procedures using pins, PDS-slings or hook plates are still widely used concurring with recently raising minimally invasive, arthroscopic techniques using new implants designed to remain in situ. Combined coracoclavicular and acromioclavicular repair are gaining in importance to restore horizontal as well as vertical ACJ stability.

Acromioclavicular joint separations

Acromioclavicular (AC) joint separations are common injuries of the shoulder girdle, especially in the young and active population. Typically the mechanism of this injury is a direct force against the lateral aspect of the adducted shoulder, the magnitude of which affects injury severity. While low-grade injuries are frequently managed successfully using non-surgical measures, high-grade injuries frequently warrant surgical intervention to minimize pain and maximize shoulder function. Factors such as duration of injury and activity level should also be taken into account in an effort to individualize each patient's treatment. A number of surgical techniques have been introduced to manage symptomatic, high-grade injuries. The purpose of this article is to review the important anatomy, biomechanical background, and clinical management of this entity.

Navigated versus conventional transfixation of AC joint injuries: feasibility and accuracy

OBJECTIVE

Transfixation of the acromioclavicular (AC) joint is a well-established technique for treating Rockwood IV to VI lesions. However, several complications, including pin breakage or pin migration due to incorrect placement, have been reported in the literature. A cadaveric study was performed to investigate whether the use of 3D navigation might improve the accuracy of AC joint transfixation.

METHODS

Seventeen transfixations of the AC joint (8 non-navigated, 9 navigated) were performed minimally invasively in cadaveric shoulders. For the navigated procedures, a 3D C-arm (Ziehm Vision FD Vario 3D) and a navigation system (BrainLab VectorVision) were used. Reference markers were attached to the spina scapulae, then a 3D scan was performed and the data transferred to the navigation system. Two Kirschner wires (K-wires) were placed either freehand under fluoroscopic control (in the non-navigated group) or with the use of a navigated drill guide. Radiological analysis was performed with OsiriX software, measuring the distance of the K-wires from the center of the AC joint. For statistical analysis, Student's t-test was performed, with the significance level being set to p < 0.05.

RESULTS

The maximum distance of the K-wires from the center of the AC joint was 5.4 ± 1.1 mm for the freehand non-navigated group and 3.1 ± 1.6 mm for the navigated group (p = 0.0054). The minimum distance of the K-wires from the AC joint center was 3.0 ± 0.6 mm for the freehand group and 1.6 ± 0.6 mm for the navigated group (p = 0.0002). The radiation time was significant lower for the freehand group (41.25 ± 20.4 seconds versus 79.5 ± 13.3 seconds for the navigated group, p = 0.004). There was no statistical difference between the groups with respect to the time required for surgery (11.25 ± 3.6 min for the freehand group and 12.6 ± 4.6 min for the navigated group; p = 0.475). In the freehand group, the AC joint was penetrated by both K-wires in 87.5% of the procedures, compared to 100% in the navigated group. Both K-wires were placed completely intraosseously in the clavicula in 50% of the procedures in the freehand group, compared to 88% in the navigated group.

CONCLUSION

Three-dimensional navigation may improve the accuracy of AC joint transfixation techniques. However, the radiation time is increased when using the navigated procedure, while the overall operation time remains comparable. Nevertheless, a 3D C-arm with a variable isocentric design is recommended for the acquisition of the shoulder scans.

Acromioclavicular and coracoclavicular PDS augmentation for complete AC joint dislocation showed insufficient properties in a cadaver model

PURPOSE

Optimal surgical treatment of high-grade acromioclavicular joint dislocations is still controversially discussed. The purpose of the present controlled laboratory study was to evaluate whether a polydioxansulfate (PDS(®)) cord augmentation with separate reconstruction of the coracoclavicular (CC) ligaments and the acromioclavicular (AC) complex provides sufficient vertical stability in a biomechanical cadaver model.

METHODS

Twenty-four shoulders of fresh-frozen cadaveric specimen were tested. Cyclic loading and load to failure protocol was performed in vertical direction on 12 native AC joints and repeated after reconstruction. The reconstruction of the coracoclavicular ligament was performed using two CC PDS cerclages and an additional AC PDS cerclage.

RESULTS

In static load testing for vertical force, the native AC joint complex measured 590.1 N (±95.8 N), elongation 13.4 mm (±2.1 mm) and stiffness 48.7 N/mm (±12.0 N/mm). The mean maximum load to failure in the reconstructed joints was 569.9 N (±97.9 N), elongation 18.8 mm (±4.7 mm) and stiffness 37.9 N/mm (±8.0 N/mm). During dynamic testing of the reconstructed AC joints, all specimens reached the critical elongation of 12.0 mm, defined as clinical failure between 200 and 300 N. The mean amount of repetitions at clinical failure was 305. A plastic deformation of the reconstructed specimens throughout cyclic loading could not be detected.

CONCLUSION

The AC joint reconstruction with acromioclavicular and coracoclavicular PDS cord cerclages did not provide the aspired vertical stability in a cadaver model.

LEVEL OF EVIDENCE

Basic Science Study.

Current concepts in the treatment of acromioclavicular joint dislocations

PURPOSE

To conduct a systematic review of the literature in relation to 3 considerations in determining treatment options for patients with acromioclavicular (AC) joint dislocations: (1) operative versus nonoperative management, (2) early versus delayed surgical intervention, and (3) anatomic versus nonanatomic techniques.

METHODS

The PubMed database was searched in October 2011 using the single term acromioclavicular and the following search limits: any date, humans, English, and all adult (19+). Studies were included if they compared operative with nonoperative treatment, early with delayed surgical intervention, or anatomic with nonanatomic surgical techniques. Exclusion criteria consisted of the following: Level V evidence, laboratory studies, radiographic studies, biomechanical studies, fractures or revisions, meta-analyses, and studies reporting preliminary results.

RESULTS

This query resulted in 821 citations. Of these, 617 were excluded based on the title of the study. The abstracts and articles were reviewed, which resulted in the final group of 20 studies that consisted of 14 comparing operative with nonoperative treatment, 4 comparing early with delayed surgical intervention, and 2 comparing anatomic with nonanatomic surgical techniques. The lack of higher level evidence prompted review of previously excluded studies in an effort to explore patterns of publication related to operative treatment of the AC joint. This review identified 120 studies describing 162 techniques for operative reconstruction of the AC joint.

CONCLUSIONS

There is a lack of evidence to support treatment options for patients with AC joint dislocations. Although there is a general consensus for nonoperative treatment of Rockwood type I and II lesions, initial nonsurgical treatment of type III lesions, and operative intervention for Rockwood type IV to VI lesions, further research is needed to determine if differences exist regarding early versus delayed surgical intervention and anatomic versus nonanatomic surgical techniques in the treatment of patients with AC joint dislocations.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and Level III studies and one case series.

Anatomic considerations of transclavicular-transcoracoid drilling for coracoclavicular ligament reconstruction

HYPOTHESIS

Acromioclavicular (AC) joint injuries vary in severity and damage to the AC and coracoclavicular (CC) ligaments. We hypothesized that transclavicular-transcoracoid drilling techniques, which allow for arthroscopic passage and fixation of tendon grafts in bone sockets to replace the insufficient conoid and trapezoid ligaments, cannot restore the footprints of the conoid and trapezoid ligaments without significant risk of cortical breach and coracoid fracture.

MATERIALS AND METHODS

Data from a prospective computed tomography shoulder registry were used to create 23 distinct shoulders. Three-dimensional models were constructed the shoulders in which virtual CC ligament reconstruction tunnels were superimposed using previously described anatomic distances and landmarks.

RESULTS

Transclavicular-transcoracoid techniques resulted in mean remaining medial and lateral wall thicknesses before cortical breach of 7.3 ± 1.7 and 7.0 ± 1.6 mm, respectively. The distance from the entry point of this tunnel from the anatomic midpoint of the CC ligaments was 9.9 ± 2.2 mm. Attempts to recapitulate the CC ligament anatomy by using anatomic distances and landmarks with transcoracoid, transclavicular techniques resulted in medial cortical breach of the coracoid in 91.3% of the shoulders.

CONCLUSION

Transclavicular-transcoracoid reconstructive techniques cannot restore the footprints of the conoid and trapezoid ligaments without significant risk of cortical breach and fracture. Attempts to correct this nonanatomic configuration by creating a tunnel based on the anatomic footprints results in a nearly universal medial cortical breach of the coracoid process.

Acute surgical treatment of acromioclavicular dislocation type V with a hook plate: superiority to late reconstruction

BACKGROUND

Outcomes for patients with acromioclavicular joint dislocation, Rockwood type V, treated with acute or delayed hook plate surgery were investigated.

MATERIALS AND METHODS

Patients treated with a hook plate for acromioclavicular joint dislocation, Rockwood type V, were retrospectively evaluated 1 to 8 years after the injury. Of 41 patients, 37 were re-evaluated, 32 in person and 5 by telephone or letter. The acute surgery group comprised 22 patients operated on with a hook plate within 4 weeks after the injury. The delayed surgery group comprised 15 patients, with unacceptable pain or functional disability after a minimum of 4 months of conservative treatment, who were operated on with modified Weaver-Dunn procedure augmented with a hook plate. The evaluation was based on radiographs, registration of activity level, and shoulder function.

RESULTS

The median Constant Score was 91 for the acute surgery group and 85 for the delayed surgery group (P = .097). The acutely treated patients had better outcomes according to the median Shoulder Pain and Disability Index (SPADI; P = .006), shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH; P = .002), and Subjective Shoulder Value (P = .032). The acutely treated patients had less pain in their injured shoulder during rest (P = .014) and during movement (P = .005). There was a significant difference in subluxation between the groups in favor of the acute group, shown by weighted radiographs (P = .011), but no significant relation between subluxation on the weighted radiographs and the shoulder function according to Constant Score at follow-up (r(s) = .122, P = .619).

CONCLUSIONS

Patients treated with acute surgery had a more satisfactory outcome than those with late surgery after failed conservative treatment.

Acromioclavicular joint injuries in National Collegiate Athletic Association football: data from the 2004-2005 through 2008-2009 National Collegiate Athletic Association Injury Surveillance System

BACKGROUND

Injuries to the shoulder are common in collegiate football, and injuries to the acromioclavicular (AC) joint have previously accounted for up to 41% of all shoulder injuries.

PURPOSE

To determine the incidence and epidemiology of injury to the AC joint in National Collegiate Athletic Association (NCAA) football athletes.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

The NCAA Injury Surveillance System (ISS) men's football database was reviewed from the 2004-2009 playing seasons. The exposure data set from the same years was reviewed for the purposes of computing rates of injury per athlete exposure (AE). The injury rate (number of injuries divided by number of AEs) was computed per 10,000 AEs for competition and practice exposures. Ninety-five percent confidence intervals (95% CIs) for the incidence rates were calculated using assumptions of a Poisson distribution.

RESULTS

According to the estimates made by the NCAA ISS, a total of 748 injuries to the AC joint occurred in NCAA football players during 2,222,155 AEs, accounting for 4.49% of all injuries sustained during this 5-year surveillance period. The overall rate of injury was 3.34 per 10,000 AEs (95% CI, 3.10-3.59). Players were 11.68 (95% CI, 10.11-13.49) times more likely to sustain an injury in games than practices. Partial sprains (types I or II) accounted for 96.4% of injuries, while complete sprains (≥type III) accounted for the remaining 3.6%. The average amount of time lost per injury was 11.61 days. Complete sprains resulted in a mean time loss of 31.9 days (95% CI, 24.4-39.6) while partial injuries resulted in 11.0 days lost (95% CI, 9.6-12.3). Overall, 2.41% of injuries underwent surgical intervention, with 22.2% of complete sprains and 1.7% of partial injuries resulting in surgery. Complete sprains of the AC joint were 13.5 (95% CI, 4.63-35.26) times more likely to result in surgical intervention than partial sprains. The majority of injuries (71.93%) resulted from contact with another player and 47.09% occurred while tackling or being tackled. Of all injuries, 47.63% occurred during offensive plays, while defense accounted for 20.77%.

CONCLUSION

AC joint injuries in NCAA football players are predominantly low-grade sprains, leading to approximately 12 days of lost competition. The few severe sprains that occurred often resulted in surgery or required approximately 5 weeks of rehabilitation.

Acromioclavicular motion after surgical reconstruction

PURPOSE

A retrospective long-term study was carried out to determine whether there was any correlation between the clinical motion of the acromioclavicular joint evaluated by a test we set up using 90° of abduction and 0° of external rotation against resistance [90°/0°RTest] and the cross arm test (compared to the healthy side) and full return to everyday activities after surgical repair.

METHODS

A clinical and radiographic evaluation was carried out on 51/80 subjects at a 5.4-year mean follow-up, treated for acromioclavicular joint dislocation with an extra-articular artificial loop, between 2000 and 2006.

RESULTS

The 25 subjects with ossifications obtained a normal acromioclavicular joint motion, on both the horizontal and vertical planes. There was a correlation between the normal motion of the reconstructed acromioclavicular joint (compared to the healthy side) in these 25 patients and full clinical recovery, whilst there was no correlation between the Constant score, the simple shoulder test, the radiographic evaluation on one hand and the clinical motion of the joint on the other. Two patients had recurrent dislocation. Three had mobilization of the screws without reduction loss, or negative clinical outcome.

CONCLUSIONS

A postoperative radiographic evaluation should be correlated with a clinical evaluation of the acromioclavicular joint motion (normal, hypermobile, unstable). Normal acromioclavicular joint motion was observed in subjects who developed significant ossifications. The study shows that the clinical evaluation of acromioclavicular joint motion is a simple and trustworthy method to assess the clinical result of a surgical repair.

LEVEL OF EVIDENCE

Diagnostic study investigating a diagnostic test, Level III.

[Post-traumatic bipolar dislocation of the clavicle: is operative treatment reasonable?]

Bipolar dislocation of the clavicle ("floating clavicle") is extremely rare. It exists no standardised treatment for this trauma and the treatment is often conservative. This is mainly an anterior displacement of the sternoclavicular joint (type III according to Allman) and a posterior dislocation of the acromioclavicular joint (type IV according to Rockwood).We report on a 60 year old male who fell onto the right shoulder. He sustained a 'floating clavicle' and had a massive dislocation, impairment of range of motion and pain. Venous congestion was observable. We stabilised the dislocated acromioclavicular joint with a Balser's plate, the sternoclavicular joint was fixed with PDS cord tension band technique around the first rip and the sternum. In addition we resected the anterior part of the distal clavicle to get a better cosmetic result. Post-operatively the patient had an excellent range of motion without any further symptoms after six weeks and one year. Venous congestion was not more observable.In most of the cases dislocations of both ends of the clavicle are treated conservatively. We recommend an operative treatment especially in young and active patients to avoid re-dislocation and to archive better cosmetic results.