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

A modified single-endobutton technique combined with nice knot for treatment of Rockwood type III or V acromioclavicular joint dislocation

PURPOSE

Double-endobutton technique, as a widely accepted strategy for the treatment of acromioclavicular joint dislocation, is undergoing constant improvement. This study aims to assess the clinical effect of a modified single-endobutton combined with the nice knot in the fixation of Rockwood type III or V acromioclavicular joint dislocation.

METHODS

From January 2016 to June 2019, 16 adult patients (13 males and 3 females) with Rockwood type III or V acromioclavicular joint dislocation were treated with a modified single-endobutton technique combined with the nice knot in our department. The age ranged from 18 to 64 years old with an average of 32.8 years old. Operative time, intraoperative blood loss, post-operative clinical outcomes and radiographic results were recorded and analyzed. Preoperative and last follow-up scores in the Constant-Murley Scale, Neer score, Rating Scale of the American Shoulder and Elbow Surgeons and VAS scale and complications such as infection, re-dislocation, implant loosening, medical origin fracture and hardware pain were recorded and evaluated.

RESULTS

Sixteen patients were followed up for 6 to 18 months with an average of 10.3 months. The operative time was 50-90 min with an average of (62.5 ± 3.10) min. The intraoperative blood loss was 30-100 ml, with an average of (55.0 ± 4.28) ml. The complications, such as wound infection, internal fixation failure and fractures, were not found in these cases. According to Karlsson criteria, there were excellent in 14 cases, good in 2 cases at the final follow-up. The mean VAS score of the patients was 5.88 ± 0.26 preoperatively, compared with 0.19 ± 0.14 at the final follow-up evaluation. The difference was statistically significant (P < 0.05). The mean Constant score was 45.5 ± 2.0 preoperatively, compared to 94.0 ± 0.73 at the final follow-up evaluation. The difference was statistically significant (P < 0.05). Patients had statistically significant preoperative and postoperative AC (acromioclavicular distance) and CC (coracoclavicular distance) distances (P < 0.05); 6 months postoperatively the AC(P = 0.412) and CC(P = 0.324) distances were not statistically significant compared to the healthy side.

CONCLUSION

Nice knot provides a reliable fixation for the single-endobutton technique in the treatment of acromioclavicular dislocations. The modified single-endobutton technique combined with the nice knot can achieve good clinical outcomes in the treatment of Rockwood type III or V acromioclavicular joint dislocation.

Allo- and autografts show comparable outcomes in chronic acromioclavicular joint reconstruction: a systematic review

PURPOSE

The aim of this review was to compare clinical and radiological outcome of acromio-clavicular joint reconstruction with allografts versus autografts.

METHODS

The PubMed, MEDLINE, The Cochrane Library and WEB OF SCIENCE databases were searched in accordance with the PRISMA guidelines until February 2020 using the terms: 'coracoclavicular' OR 'coraco-clavicular' OR 'acromioclavicular' OR 'acromio-clavicular joint', AND 'reconstruction'. All studies reporting on clinical and radiological outcome as well as complications after ACJ reconstruction using allo- and/or autografts were included.

RESULTS

A total of 29 articles, including 2 prospective and 27 retrospective studies, involving 622 patients, reconstructed with either allo- (n = 360) or auto-grafts (n = 262), for acromio-clavicular joint instability were identified and included in this review. The majority of studies had low sample sizes (66.7% below n = 20), were retrospective (93.3%), with short-term follow-ups (average 26.2 ± 12.6 months; range 6-186). The study with the largest sample size (n = 128) did not report clinical outcome. A comparison between allo- and auto-graft showed no significant differences regarding age, gender, and follow-up times. Clinical outcome was comparable in both groups, loss of reduction (LOR) and complication rates were higher in the allograft group. Overall a reduction of LOR was shown if additional horizontal stabilization was performed. Also a higher LOR and revision rate was documented in allografts without suture or suture-tape augmentation. The use of more clavicular drill-holes correlated with a higher frequency of fracture.

CONCLUSIONS

A systematic review of the available peer-reviewed literature addressing allograft and autograft reconstruction of unstable coracoclavicular ligaments shows that the published studies are generally of low quality with low levels of evidence. The published literature shows no significant difference in clinical outcomes between the use of autografts or allografts in ACJ reconstruction surgery. Surgical techniques utilizing additional horizontal stabilization may contribute to lower rates of LOR. In cases where allograft tissue is used for ACJ reconstruction the use of suture/tape augmentation may reduce LOR rates as well as revision rates.

LEVEL OF EVIDENCE

III.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ultrasound of horizontal instability of the acromioclavicular joint : A simple and reliable test based on a cadaveric study

Background

Horizontal instability influences the clinical outcome after acromioclavicular joint (ACJ) injuries and in joint degeneration. A standardized, dynamic examination of the horizontal instability has not been described before. This current study presents a sonographic method to analyze the dynamics between the clavicle and acromion in the horizontal plane.

Methods

The horizontal joint play, the ACJ space and the offset between clavicle and acromion were sonographically assessed by a 45° ventrally angulated longitudinal section. A total of four investigators with different experience in the field of musculoskeletal ultrasound examining 20 ACJs in 10 human cadavers. Measurements in the absence of any pressure and under standardized anterior and posterior pressure onto the clavicle were carried out in different ligament status intact acromioclavicular (AC) and coracoclavicular (CC) ligaments as well as in a Rockwood (RW) II and III model. A two-sided t‑test was used to examine the differences between joint positions and ligament status.

Results

The horizontal joint play was 1.3 ± 0.9 mm with intact ligaments, 1.4 ± 1.2 mm by transecting the AC ligaments and 1.9 ± 1.3 mm after additionally transecting the CC ligament. The joint space was 3.3 ± 1.1 mm with intact ligaments, 4.1 ± 1.8 mm in an iatrogenic RW 2 injury, and 5.3 ± 3.3 mm in an iatrogenic RW 3 injury. Manipulating the clavicle by applying anterior or posterior pressure did not change the difference within one injury pattern. Interobserver reliability was 83.9%.

Conclusion

Apart from evaluating the ligaments and the joint capsule, measurement of the dynamic horizontal instability is possible in a human cadaver model. The ultrasound-based measurement of horizontal instability dynamics avoids radiation exposure, is readily available and cost-efficient.

New quantitative radiographic parameters for vertical and horizontal instability in acromioclavicular joint dislocations

PURPOSE

The aim of this study was to identify the most accurate and reliable quantitative radiographic parameters for assessing vertical and horizontal instability in different Rockwood grades of acromioclavicular joint (ACJ) separations. Furthermore, the effect of projectional variation on these parameters was investigated in obtaining lateral Alexander view radiographs.

METHODS

A Sawbone model of a scapula with clavicle was mounted on a holding device, and acromioclavicular dislocations as per the Rockwood classification system were simulated with the addition of horizontal posterior displacement. Projectional variations for each injury type were performed by tilting/rotating the Sawbone construct in the coronal, sagittal or axial plane. Radiographic imaging in the form of an anterior-posterior Zanca view and a lateral Alexander view were taken for each injury type and each projectional variation. Five newly defined radiographic parameters for assessing horizontal and vertical displacement as well as commonly used coracoclavicular distance view were measured. Reliability, validity and the effect of projectional variation were investigated for these radiographic measurements.

RESULTS

All radiographic parameters showed excellent intra- and interobserver reliability. The validity was excellent for the acromial centre line to dorsal clavicle (AC-DC) in vertical displacement and for the glenoid centre line to posterior clavicle (GC-PC) in horizontal displacement, whilst the remaining measurements showed moderate validity. For AC-DC and GC-PC, convergent validity expressed strong correlation to the effective distance and discriminant validity demonstrated its ability to differentiate between various grades of ACJ dislocations. The effect of projectional variation increased with the degree of deviation and was maximal (3 mm) for AC-DC in 20° anteverted malpositioning and for GC-PC in 20° retroverted malpositioning.

CONCLUSIONS

AC-DC and the GC-PC are two novel quantitative radiographic parameters of vertical and horizontal instability in ACJ dislocations that demonstrate excellent reliability and validity with reasonable inertness to malpositioning. The use of AC-DC for assessing vertical displacement and GC-PC for assessing horizontal displacement in a single Alexander view is recommended to guide the appropriate management of ACJ dislocations. A better appreciation of the degree of horizontal instability, especially in lower Rockwood grades (II, III) of ACJ dislocations, may improve management of these controversial injuries.

Modified closed-loop double-endobutton technique for repair of rockwood type III acromioclavicular dislocation

Acromioclavicular dislocation (ACD) is a common injury. According to the Rockwood classification, ACD is classified into six types (type I–VI); however, for type III injuries, it remains controversial whether or not operative treatment should be applied. Numerous studies have advocated early surgical treatment to ensure early rehabilitation activities. Thus, the present study aimed to investigate a modified closed-loop double-endobutton technique (MCDT), that may be used to repair Rockwood type III ACD. In the current study, 61 patients with Rockwood type III ACD were enrolled during a period of 5 years at the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University. Patients were divided into three groups according to the surgical method used, the MCDT group (n=20), the common closed-loop double-endobutton technique (CCDT) group (n=21), and the clavicular hook plate fixation (CHPF) group (n=20). Preoperative and intraoperative information were recorded. Furthermore, the functional scores of injured shoulder were evaluated prior to surgery and following surgery with a 1-year follow-up. Among the three groups, postoperative functional scores were significantly more improved compared with those prior to surgery (P<0.05), and no significant difference was observed regarding the coracoclavicular interval with the 1-year follow-up (P>0.05). Postoperative functional scores in the MCDT and CCDT groups were significantly more improved compared those in the CHPF group (P<0.05). In addition, the duration of surgery in the MCDT group was significantly shorter compared with that in the CCDT group (P<0.05). Furthermore, compared with the CHPF group, the incision length was significantly shorter with reduced hemorrhage in the MCDT group (P<0.05). In conclusion, the results of the current study suggest that MCDT is more simple, convenient and efficient compared with CCDT, and is worth popularizing.

Management of chronic unstable acromioclavicular joint injuries

Abstract

The acromioclavicular joint represents the link between the clavicle and the scapula, which is responsible for the synchronized dynamic of the shoulder girdle. Chronic acromioclavicular joint instability involves changes in the orientation of the scapula, which provokes cinematic alterations that might result in chronic pain. Several surgical strategies for the management of patients with chronic and symptomatic acromioclavicular joint instability have been described. The range of possibilities includes anatomical and non-anatomical techniques, open and arthroscopy-assisted procedures, and biological and synthetic grafts. Surgical management of chronic acromioclavicular joint instability should involve the reconstruction of the torn ligaments because it is accepted that from three weeks after the injury, these structures may lack healing potential. Here, we provide a review of the literature regarding the management of chronic acromioclavicular joint instability.

Level of evidence

Expert opinion, Level V.

Prevalence of remaining horizontal instability in high-grade acromioclavicular joint injuries surgically managed

PURPOSE

To determine the prevalence of remaining horizontal instability in high-grade acromioclavicular joint (ACJ) injuries surgically managed by means of four different surgical strategies and to assess its relation to the clinical outcomes and the quality of life.

METHODS

In this multicentric non-randomized retrospective study, 53 patients with high-grade ACJ injuries surgically managed (by means of open or arthroscopic surgery) were clinically and radiographically assessed at 24 months or more after shoulder surgery. The presence of post-surgical remaining horizontal instability was evaluated by means of Alexander or axillary X-ray views. The study population was divided into two groups: patients with evidence of post-surgical remaining horizontal instability and patients without evidence of post-surgical remaining horizontal instability at the last follow-up visit. The relationship between remaining horizontal instability and the quality-of-life questionnaires was analyzed.

RESULTS

18.87% (10/53) of the Alexander or axillary X-rays views showed post-surgical remaining horizontal instability at the last follow-up visit (INSTAB-group). Results of the questionnaires were: (1) physical SF36 score (INSTAB-group 57.02 ± 3.17  and NO-INSTAB-group 57.66 ± 3.30, p = 0.583); (2) mental SF36 score (INSTAB-group 53.95 ± 3.98  and NO-INSTAB-group 55.71 ± 3.30, p = 0.150); (3) NRS for pain (INSTAB-group 1.30 ± 1.49 and NO-INSTAB-group 0.83  ± 1.08, p = 0.260); (4) DASH questionnaire (INSTAB-group 5.27 ± 5.42 and NO-INSTAB-group 3.06 ± 2.30, p = 0.049); (5) Constant score (INSTAB-group 93.4 ± 3.5 and NO-INSTAB-group 94.83  ± 4.3, p = 0.333); and Global satisfaction (INSTAB-group 8.7  ± 0.95 and NO-INSTAB-group 8.64 ± 1.03, p = 0.874).

CONCLUSION

Independently of the type of procedure, post-surgical remaining horizontal instability was present in almost one-fifth of the patients, and this group of patients showed a significantly worse DASH score. The addition of an acromioclavicular augmentation might have to be considered, taking into account that its absence may have a negative impact in terms of shoulder disabilities.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

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

Acute acromioclavicular (AC) joint injuries are common in clinical practice. The hook plate is a well-established conventional operative treatment option for high grade instability; however, arthroscopically-assisted flexible double button techniques are increasingly being used. Both procedures lead to good or excellent results. The advantages of the hook plate are the simple surgical technique and the possibility of an early functional aftercare. The minimally invasive one-step procedure with the possibility of identification and treatment of frequently concomitant glenohumeral pathologies is advantageous for the arthroscopic technique but mobilization is more restrictive. Available comparative studies have shown no significant clinical differences but a tendency towards better results with a higher degree of acceptance among patients for the arthroscopic and minimally invasive non-rigid double button procedures.

Management of acute unstable acromioclavicular joint injuries

Surgical management of acute unstable acromioclavicular joint injuries should be focused on realigning the torn ends of the ligaments to allow for healing potential. The most widely utilized treatment methods incorporate the use of metal hardware, which can alter the biomechanics of the acromioclavicular joint. This leads to a second surgical procedure for hardware removal once the ligaments have healed. Patients with unstable acromioclavicular joint injuries managed with arthroscopy-assisted procedures have shown good and excellent clinical outcomes, without the need for a second operation. These procedures incorporate a coracoclavicular suspension device aimed to function as an internal brace, narrowing the coracoclavicular space thus allowing for healing of the torn coracoclavicular ligaments. The lesser morbidity of a minimally invasive approach and the possibility to diagnose and treat concomitant intraarticular injuries; no obligatory implant removal, and the possibility of having a straight visualization of the inferior aspect of the base of the coracoid (convenient when placing coracoclavicular fixation systems) are the main advantages of the arthroscopic approach over classic open procedures. This article consists on a narrative review of the literature in regard to the management of acute acromioclavicular joint instability.

The biomechanical influence of the deltotrapezoid fascia on horizontal and vertical acromioclavicular joint stability

INTRODUCTION

Many studies have investigated the biomechanical influence of the acromioclavicular (AC) and coracoclavicular (CC) ligaments on the stability of the acromioclavicular joint (ACJ). It has been shown that augmentation of the CC ligaments alone can result in residual horizontal instability. Our hypothesis was that the DTF would have a significant stabilizing effect on horizontal ACJ stability.

MATERIALS AND METHODS

In a biomechanical in vitro study a sequential injury of the ACJ was created on eight shoulders from full body, which were placed in an upright sitting position. The translation and rotation of the clavicle were measured in relation to the acromion using an optical navigation system in various states during thoracic-humeral elevation, abduction, and horizontal adduction. The three states were: an intact shoulder, complete sectioning of the AC ligaments, and a circular lesion of the DTF.

RESULTS

Compared to the intact state we found a significant increase in anterior rotation of the clavicle of 1.11° (p = 0.012) and a tendency in lateral translation of 2.71 mm (p = 0.017) in relation to the acromion, with a combined lesion of AC ligaments and DTF. No significant differences were found between the intact state and the isolated dissected AC ligaments as well in adduction as elevation.

CONCLUSION

A combined lesion of the AC ligaments and the DTF resulted in a quantitatively small but significant increase in anterior rotation and a tendency in lateral translation of the clavicle in relation to the acromion. These differences were quantitatively small, so that the clinical relevance of the stabilization effect of combined AC ligaments and DTF injuries is questionable.

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.

Horizontal and Vertical Stabilization of Acute Unstable Acromioclavicular Joint Injuries Arthroscopy-Assisted

We describe the technical aspects of an arthroscopy-assisted procedure indicated for the management of acute unstable acromioclavicular joint injuries, consisting of a synthetic augmentation of both the coracoclavicular and acromioclavicular ligaments, that anatomically reproduces the coracoclavicular biomechanics and offers fixation that keeps the torn ends of the ligaments facing one another, thus allowing healing of the native structures without the need for a second surgical procedure for metal hardware removal.

Scapular dyskinesis and SICK syndrome in patients with a chronic type III acromioclavicular dislocation. Results of rehabilitation

PURPOSE

Scapular dyskinesis has been related to acromioclavicular injuries. A rehabilitation protocol has been studied in order to treat scapular dyskinesis, but it has not yet been evaluated. This rehabilitation programme was adopted to improve the shoulder function, thereby improving the scapular dyskinesis in patients with chronic acromioclavicular dislocation.

METHOD

Twenty-four patients diagnosed with chronic type III acromioclavicular dislocation and scapular dyskinesis that have already been conservatively treated were enrolled in the rehabilitation protocol and analysed. Fourteen of these patients had a Scapular Inferior Coracoid dysKinesis (SICK) Syndrome. The adopted rehabilitation protocol consisted of 12 strengthening and stretching exercises of the scapulae. The final follow-ups were performed after 6 weeks, 6 months and 12 months using clinical measurements of scapular position and clinical evaluation of the scapular motion. In order to evaluate the SICK scapula syndrome, we used the SICK Scapula Rating Scale. The shoulder function was evaluated with a Constant Score and a Subjective Shoulder Value.

RESULTS

After 12 months, the follow-up concluded that the scapular dyskinesis was no longer present in 18/23 patients (78.2 %). SICK scapula syndrome was observed in 4/8 patients with a scapular malposition. The Scapula Rating Scale score in 4 patients with SICK scapula was 7.5 points. After 12 months of rehabilitation, the mean Constant Score and Subjective Shoulder Value grew up to 85 points.

CONCLUSION

The scapular dyskinesis and SICK syndrome secondary to chronic type III AC dislocation can be treated with the proposed rehabilitation protocol resulting in positive improvements of the shoulder function within 6 weeks; however, patients that do not respond to the rehabilitation programme will not improve with extended rehabilitation time. It is important to advise patients of the specific exercises for the prevention/treatment of scapular dyskinesis in the rehabilitation programme after AC joint dislocation.

LEVEL OF EVIDENCE

IV.

Managing and recognizing complications after treatment of acromioclavicular joint repair or reconstruction

Complications of the acromioclavicular joint injuries can occur as a result of the injury itself, conservative management, or surgical treatment. Fortunately, the majority of acromioclavicular surgeries utilizing modern techniques and instrumentation result in successful outcomes. However, clinical failures do occur with frequency. The ability to identify the causative factor of failures makes revision surgery more likely to be successful. The purposes of this review are to highlight common problems that can occur following acromioclavicular joint surgery and discuss techniques that can be utilized in revision surgery.