[Injuries of the acromioclavicular joint: Hook plate versus arthroscopy]

Both Arthroscopically Assisted Suture Button and Hook Plate Are Effective in Treating Acute High-grade Acromioclavicular Joint Dislocation: A Systematic Review

PURPOSE

To conduct a systematic review of clinical studies comparing the clinical outcomes of arthroscopically assisted suture button (AASB) and hook plate (HP) in the treatment of acute high-grade acromioclavicular joint (ACJ) dislocation to determine which technique provides superior clinical benefits.

METHODS

Two independent researchers conducted literature searches on the basis of Preferred Reporting Items from Systematic Reviews and Meta-analyses guidelines. PubMed, EMBASE, and the Cochrane Library were searched for studies that compared AASB and HP in treating acute high-grade (grade Ⅲ and greater) ACJ dislocation. Inclusion criteria included clinical studies that compared AASB and HP for acute Rockwood type III or greater dislocations with evaluations of functional outcomes (Constant score [CS], pain score, American Shoulder and Elbow Surgeons score, Disabilities of the Arm, Shoulder and Hand). Studies were excluded if they were case reports, reviews, or had missing data, revision procedures, or had loss to follow-up >20%. The methodologic quality of the included studies was assessed on the basis of Newcastle-Ottawa scale.

RESULTS

In this systematic review, 14 studies with 782 participants were included, all of which were classified as Level III-IV evidence. The analysis of 12 studies showed that the AASB group (81.9-95.31) had only slightly greater postoperative CS compared with the HP group (77.5-92.38), with 9 studies reporting significant improvements, whereas 3 studies found no significant difference compared with the HP group. For pain outcomes, 4 studies showed lower pain score in the AASB group, whereas the rest found no significant difference; the visual analog scale scores ranged from 0.3 to 3.61 in the AASB group and 0.5 to 4.9 in the HP group. Operation time was generally longer in the AASB group (AASB: 48.3-89.39 minutes; HP: 40.77-76.5 minutes). Complication rates were similar (AASB: 0%-50%; HP: 0%-36.36%), with only 1 study reporting a greater incidence in the AASB group. Minimal clinically important difference analysis from 3 studies showed clinically significant improvements in CS with AASB, but no significant difference between AASB and HP for pain outcomes.

CONCLUSIONS

AASB shows comparable outcomes to HP for acute high-grade ACJ dislocations, with similar ranges in clinical scores and complication rates. Although AASB shows some advantages in functional outcomes, the differences between the 2 methods are minimal, suggesting that both approaches are effective and safe.

LEVEL OF EVIDENCE

Level IV, systematic review of Level Ⅲ-IV studies.

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.

Efficacy of Transosseous Tunnel Placement for Triple Endobutton Plate in Acromioclavicular Joint Reconstruction: A Three-Dimensional Printing Guide Design Technology

Objective

Explore an accurate transosseous tunnel drilling method based on three‐dimensional (3D) printing technology for acromioclavicular joint reconstruction (ACD), design a guide design, and evaluate its accuracy.

Methods

Using Mimics software to reconstruct 100 cases of acromioclavicular joint computed tomography (CT) data. In design 2, the non‐collinear tunnel is superimposed on the 3D model, and a virtual drilling is performed between the clavicle and the coracoid using a triple inner gusset. Then, in the Geomagic Studio software model, an elliptical plane is calculated and extracted as a guide design for precise drilling. Then put the design and the 3D shoulder model together for 3D printing. Ten lengths were measured, and the effects of the virtual model, the actual model, and the guide rail design were compared.

Results

We successfully compared 10 parameters of 3D virtual model and actual model. There was no significant difference between actual and virtual bone tunnels in 10 measurements (P > 0.05).

Conclusions

The accuracy of ACD combined with 3D printing guidance design technology in the transosseous tunnel of adult shoulder is reliable.

[Arthroscopically-assisted treatment of acute and chronic dislocations of the acromioclavicular joint : A prospective clinical trial]

BACKGROUND

Injuries of the acromioclavicular joint (ACJ) are frequent and often occur during sports. While arthroscopically-assisted stabilization of acute injuries of the ACJ is a well-established procedure, there is not much data available for arthroscopically-assisted stabilization of chronic injuries of the ACJ.

OBJECTIVES

This study assesses clinical and radiological results of arthroscopically-assisted stabilization of acute and chronic injuries of the ACJ.

MATERIALS AND METHODS

Thirty-six patients with acute and chronic injuries of the ACJ were assessed in a prospective clinical trial. Twenty-five patients with acute injuries (group A) and eleven patients with chronic injuries (group B) were included in this study. Patients of group A were operated using two suture-button systems, while patients of group B received one suture-button system and an autologous gracilis tendon graft.

RESULTS

In group A, the mean preoperative Constant score rated 38, and the ASES score rated 34. At follow-up the Constant score (92) and the ASES score (89) had improved. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (15.8 mm) in comparison to the contralateral shoulder (10.9 mm). In group B, the preoperative Constant score measured 57. It improved to 72 points at follow-up. The ASES score improved from 39 to 72 points in the same period. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (18.9 mm) in comparison to the contralateral shoulder (12.4 mm).

CONCLUSIONS

Stabilization of acute injuries of the ACJ with two suture-button systems is related to very good shoulder function after one year. The native coracoclavicular distance cannot be restored with this procedure. Stabilization of chronic injuries of the ACJ with a suture-button system and an autologous gracilis tendon graft is related to improved shoulder function after one year. However, shoulder function cannot be fully restored with the stabilization technique presented.

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.

Early clinical results of minimally invasive coracoclavicular ligament reconstruction can be maintained at a minimum of five years' follow-up

AIMS

There is a lack of long-term data for minimally invasive acromioclavicular (AC) joint repair. Furthermore, it is not clear if good early clinical results can be maintained over time. The purpose of this study was to report long-term results of minimally invasive AC joint reconstruction (MINAR) and compare it to corresponding short-term data.

METHODS

We assessed patients with a follow-up of at least five years after minimally invasive flip-button repair for high-grade AC joint dislocation. The clinical outcome was evaluated using the Constant score and a questionnaire. Ultrasound determined the coracoclavicular (CC) distance. Results of the current follow-up were compared to the short-term results of the same cohort.

RESULTS

A total of 50 patients (three females, 47 males) were successfully followed up for a minimum of five years. The mean follow-up was 7.7 years (63 months to 132 months). The overall Constant score was 94.4 points (54 to 100) versus 97.7 points (83 to 100) for the contralateral side showing a significant difference for the operated shoulder (p = 0.013) The mean difference in the CC distance between the operated and the contralateral shoulder was 3.7 mm (0.2 to 7.8; p = 0.010). In total, 16% (n = 8) of patients showed recurrent instability. All these cases were performed within the first 16 months after introduction of this technique. A total of 84% (n = 42) of the patients were able to return to their previous occupations and sport activities. Comparison of short-term and long-term results revealed no significant difference for the Constant Score (p = 0.348) and the CC distance (p = 0.974).

CONCLUSION

The clinical outcome of MINAR is good to excellent after long-term follow-up and no significant differences were found compared to short-term results. We therefore suggest this is a reliable technique for surgical treatment of high-grade AC joint dislocation. Cite this article: Bone Joint J 2020;102-B(7):918-924.

Acromioclavicular joint disruptions: A comparison of two surgical approaches 'hook' and 'rope'

INTRODUCTION

Acromioclavicular joint injuries are common shoulder girdle injuries most commonly resulting from a direct blow to the acromion with the arm adducted. Type-I or type-II acromioclavicular joint injuries can be managed with sling immobilization, early shoulder motion, and physiotherapy. The management of type-III injuries remains controversial and is individualized. Type IV and V injuries should be treated surgically. A myriad of surgical techniques for the management of acromioclavicular joint injuries have been reported.

METHODS

We present a comparative study of 76 patients treated with two most common modalities of treatment for AC joint disruption and that is Hook plate stabilisation (n=52) or arthroscopically assisted tight rope stabilisation (n=24). The primary objective was to establish whether hook plate stabilization was superior compared to arthroscopic tight rope fixation in reducing pain and increasing function in the short-term and long-term for patients with AC joint disruptions III-IV. We also wanted to assess how quickly patients returned to their work/job. It was a prospective study, we included all the patients operated between 2008 and 2015 for AC joint disruption by the two shoulder surgeons of our department. All patients followed a strict physiotherapy protocol and were assessed at 6 weeks, 3 months and 12 months. We used the Harm and cost criteria of assessment and the patient specific functional outcome scores.

RESULTS

Both modalities of treatment have high patient satisfaction rate, return to work is faster in tight rope group but after a year both group of patients returned to their premorbid state. Removal of hook plate is not mandatory and lysis of acromion is rare (1% in our series).

CONCLUSION

Despite the fact that both methods yielded similar results and have statistically similar number of complications, the type of postoperative complications was different between groups. The plate group had more postoperative pain and worse function but both aspects improved after plate removal. The rope group had more complex complications including deep infection and recurrence of deformity and fracture. These differences should be taken into consideration when consenting the patient regarding possible treatment.

Different treatment strategies for acromioclavicular dislocation injuries: a nationwide survey on open/minimally invasive and arthroscopic concepts

Background

Injuries to the acromioclavicular (AC) joint are one of the most common among sporting injuries of the upper extremity. Several studies investigated different treatment options comparing surgical and non-surgical treatment, and type of operative interventions. This study aims to evaluate treatment decisions regarding injuries of the AC joint and to compare different treatment strategies depending on the specific training of the treating physician.

Methods

We performed a nationwide survey by contacting different experienced physicians and sending them questionnaires. The questionnaire included 37 questions that assessed preferred treatment strategies in AC joint injuries. We addressed different surgical and nonsurgical options as well as level of experience and factors that might influence the decision on treatment strategy. The physicians were stratified according to their training into general surgeons (group trauma associated) and orthopedic surgeons (orthopedic associated). The AC joint lesions were categorized according to the widely used Rockwood classification.

Results

This study analyses 96 questionnaires. We included 46 (47.9%) colleagues in group trauma and 50 (52.1%) in group orthopedics. Most of the colleagues (98.9%) prefer non-operative treatment of type I and type II AC lesions. Similarly, 96.8% agree on surgical treatment of types IV, V, and VI lesions. The treatment of type III lesions is performed in 41.6% of cases non-operatively and in 58.4% of cases surgically. Trauma-associated colleagues are 3.4 times more likely to treat AC lesions with a hook plate compared to orthopedic-associated colleagues (p = 0.05). In decreasing order, the most commonly used non-surgical technique is sling immobilization (63.7%), and the most commonly performed surgical treatment is the hook plate (41.1%) in treating type III injuries.

Conclusion

This study shows a distinct difference in treatment of AC joint injuries depending on the training of the physician. Further, the need for high-quality studies arises to define the optimal treatment of type III lesions.

Short-term outcomes of arthroscopic TightRope® fixation are better than hook plate fixation in acute unstable acromioclavicular joint dislocations

AIM

The aim of this study was to compare the short-term outcomes of arthroscopic TightRope^® fixation with that of hook plate fixation in patients with acute unstable acromioclavicular joint dislocations.

PATIENTS AND METHODS

We conducted a prospective case-control study of twenty-six patients with an acute ACJ dislocation who underwent surgical repair with either an arthroscopic TightRope^® fixation or a hook plate from 2013 to 2016. Clinical and radiological data were collected prospectively. Clinical outcomes were evaluated using the Constant Score, the University of California at Los Angeles (UCLA) Shoulder Score, Oxford Shoulder Score as well as the visual analogue scale. Radiological outcomes were assessed with the coracoclavicular distance (CCD).

RESULTS

Sixteen patients underwent arthroscopic TightRope^® fixation, while 10 patients underwent hook plate fixation. There were no significant differences in the preoperative variables except for the mean UCLA 4b infraspinatus score (TightRope^® 2.8 vs. hook plate 3.8; p = 0.030). Duration of surgery was significantly longer in the TightRope^® group. At 1 year post-operatively, the TightRope^® group had a significantly better Constant Score and CCD with no complications. All patients with hook plate fixation had to undergo a second procedure for removal of implant, and 3 patients had complications.

CONCLUSIONS

Arthroscopic TightRope^® fixation is a good option for the treatment of acute unstable ACJ dislocations. It has better short-term clinical and radiological outcomes as well as lesser complications when compared to hook plate fixation.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Concomitant glenohumeral pathologies associated with acute and chronic grade III and grade V acromioclavicular joint injuries

PURPOSE

The purpose of this study was to identify the risk of concomitant glenohumeral pathologies with acromioclavicular joint injuries grade III and V.

METHODS

Patients who underwent arthroscopically-assisted stabilization of acromioclavicular joint injuries grade III or grade V between 01/2007 and 12/2015 were identified in the patient databases of two surgical centres. Gender, age at index surgery, grade of acromioclavicular joint injury (Rockwood III or Rockwood V), and duration between injury and index surgery (classified as acute or chronic) were of interest. Concomitant glenohumeral pathologies were noted and their treatment was classified as debridement or reconstructive procedure.

RESULTS

A total of 376 patients (336 male, 40 female) were included. Mean age at time of arthroscopic acromioclavicular joint reconstruction surgery was 42.1 ± 14.0 years. Overall, 201 patients (53%) had one or more concomitant glenohumeral pathologies. Lesions of the biceps tendon complex and rotator cuff were the most common. Forty-five patients (12.0%) had concomitant glenohumeral pathologies that required an additional repair. The remaining 156 patients (41.5%) received a debridement of their concomitant pathologies. Rockwood grade V compared to Rockwood grade III (p = 0.013; odds ratio 1.7), and chronic compared to acute injury were significantly associated with having a concomitant glenohumeral pathology (p = 0.019; odds ratio 1.7). The probability of having a concomitant glenohumeral pathology was also significantly associated with increasing age (p < 0.0001).

CONCLUSIONS

Concomitant glenohumeral pathologies were observed in 53% of surgically treated patients with an acute or chronic acromioclavicular joint injury of either grade III or V. Twenty-two percent of these patients with concomitant glenohumeral pathologies received an additional dedicated repair procedure. Although a significant difference in occurrence of concomitant glenohumeral pathologies was seen between Rockwood grades III and V, and between acute and chronic lesions, increasing age was identified as the most dominant predictor.

LEVEL OF EVIDENCE

Level IV, case series.