Return to sport after surgical treatment for high-grade (Rockwood III-VI) acromioclavicular dislocation

Eponymous terms in acromioclavicular joint surgery

Eponymization serves as a means of paying tribute to individuals who have made significant contributions to our culture. Each eponym is often linked with a story for everyone to discover. To aid in the retention of these stories, this review offers readers an overview of the individuals behind the eponymous terms, as well as their original descriptions, within the context of acromioclavicular joint pathology and orthopaedic surgery.

Return to Play After Surgical Treatment for Acromioclavicular Joint Dislocation: A Systematic Review

BACKGROUND

Acromioclavicular (AC) joint dislocation is a common clinical problem among young and athletic populations. Surgical management is widely used for high-grade dislocations (Rockwood III-VI) and in high-demand athletes at high risk of recurrence.

PURPOSE

To systematically review the evidence in the literature to ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after surgical treatment for AC joint dislocation.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted in the PubMed database. Clinical studies were eligible for inclusion if they reported on RTP after surgical treatment for AC joint dislocation. Statistical analysis was performed with SPSS.

RESULTS

We found 120 studies including 4327 cases meeting our inclusion criteria. The majority of patients were male (80.2%), with a mean age of 37.2 years (range, 15-85) and a mean follow-up of 34.5 months. Most were recreational athletes (79%), and the most common sport was cycling. The overall rate of RTP was 91.5%, with 85.6% returning to the same level of play. Among collision athletes, the rate of RTP was 97.3%, with 97.2% returning to the same level of play. In overhead athletes, the rate of RTP was 97.1%, with 79.2% returning to the same level of play. The mean time to RTP was 5.7 months (range, 1.5-15). Specific RTP criteria were reported in the majority of the studies (83.3%); time to return to play was the most commonly reported item (83.3%). Type III Rockwood injuries had the highest RTP rate at 98.7% and the earliest RTP at 4.9 months. Among the different surgical techniques, Kirschner wire fixation had the highest rate of RTP at 98.5%, while isolated graft reconstruction had the earliest RTP at 3.6 months.

CONCLUSION

The overall rate of RTP was reportedly high after surgical treatment for AC joint dislocation, with the majority of patients returning to their preinjury levels of sport. There is a lack of consensus in the literature for what constitutes a safe RTP, with further focus on this topic required in future studies.

Management of acute grade IV and greater acromioclavicular dislocations: Open acromioclavicular brace versus arthroscopic double DogBone® endobutton

INTRODUCTION

Several surgical techniques exist to manage grade IV acute acromioclavicular dislocation (ACD). However, the conventional acromioclavicular brace technique (ACB) has never been compared to the arthroscopic DogBone® (DB) double endobutton technique. The aim of this work was to compare the functional and radiological results of DB stabilization with those of ACB.

HYPOTHESIS

DB stabilization provides similar functional results with a low rate of radiological recurrences compared to ACB.

MATERIAL AND METHODS

This is a case-control study comparing 17 cases of ACD operated by DB (DB group) between January 2016 and January 2021 with 31 cases of ACD operated by ACB (ACB group) between January 2008 and January 2016. The primary outcome was the difference in the D/A ratio (reflecting vertical displacement) measured on an anteroposterior acromioclavicular (AC) X-ray compared between the 2 groups at one-year after surgery. The secondary outcome was a clinical evaluation at one-year using the Constant score and clinical AC instability.

RESULTS

At revision, the mean D/A ratio in the DB and ACB groups was 0.4±0.5 [-0.4-1.6] and 1.6±0.3 [0.8-3.1] respectively (p>0.05). Two patients (11.7%) in the DB group had implant migration with radiological recurrence while 14 patients (33%) had radiological recurrence in the ACB group (p<0.05).

CONCLUSION

The DB technique limits the radiographic recurrence of acute ACD with an equivalent functional result at 1-year postoperatively compared to the conventional ACB technique, which implicitly requires a second operation for hardware removal. The DB technique has become the technique of choice in first-line treatment of acute grade IV ACD.

LEVEL OF EVIDENCE

III; retrospective case-control series.

Management of Acromioclavicular Injuries - Current Concepts

Introduction

Treatment of a patient with acromioclavicular joint (ACJ) injury remains challenging for orthopedic surgeons. To date, there is debate over the optimal management of ACJ injuries. This review provides an overview of assessment, treatment, and future perspectives for the treatment of and research into ACJ.

Material and Methods

A scoping literature review was performed. The search was built including the following terms: acromioclavicular joint injuries or dislocation, and pathophysiology, etiology, anatomy, treatment, and trauma mechanism. The papers with evidence levels 1-3 were included in the current narrative review.

Results

A total of 2242 potential relevant studies were identified in the searches. After removal of duplicates, 432 studies were screened on their titles and abstracts, resulting in 35 studies being included in the review, based on the eligibility criteria.

Conclusion

The management of acute and chronic ACJ injuries is not clarified in the current literature. However, there is currently insufficient high-level evidence for the overall treatment options for ACJ injuries. If surgical intervention is decided upon in consultation with the patient, the complications may not outweigh the benefits. The multitude of existing techniques is indicative of the uncertainty surrounding this issue, and no gold standard has yet been established for treatment methods. An ideal classification would include not only vertical and horizontal instability, but also the severity of kinematic alterations of the shoulder complex. This indicates the need for a new and improved diagnostic tool for the classification of ACJ injuries.

Criteria for return to play after operative management of acromioclavicular joint separation: a systematic review

Background

Acromioclavicular (AC) joint separation is a common cause of shoulder injury among athletes. High-grade injuries may require operative fixation, and comprehensive return-to-play guidelines have not yet been established. The purpose of this study was to summarize criteria for return to play after operative management of AC joint separation.

Methods

A systematic review of the literature was performed from January 1999 to April 2020 to evaluate clinical evidence regarding criteria for return to play after operative management of isolated AC joint separation.

Results

Sixty-three studies with at least 1 explicitly stated return-to-play criterion were identified out of an initial database search of 1253 published articles. Eight separate categories of return-to-play criteria were identified, the most common of which was time from surgery (95.2%). Return-to-play timelines ranged from 2 to 12 months, the most common timeline being 6 months (37.8%). Only 4 (6.3%) studies used conditional criteria to guide return to play, which included range of motion, strength, clinical stability, radiographic stability, functional assessment, safety assessment, and hardware removal.

Conclusion

Most published studies use only time-based criteria for return to play after surgery for AC joint separation, and only a small number of studies use additional subjective or objective criteria. While this systematic review helps provide a foundation for developing a comprehensive return-to-play checklist, further investigation is needed to establish safe and effective guidelines that will enable athletes to safely return to sport and minimize the recurrence of injury.

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

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

Level of Evidence

5.

Acromioclavicular Joint Separation in UEFA Soccer Players: A Matched-Cohort Analysis of Return to Play and Player Performance From 1999 to 2018

Background

Acromioclavicular joint (ACJ) separation injuries are uncommon in professional soccer players, threatening future performance and team contributions. Data regarding return to play (RTP) in professional soccer players after ACJ separation are limited.

Purpose

To determine the rate, time to RTP, and player performance after ACJ separation in soccer players from the top 5 professional European leagues when compared with a retrospective, matched cohort of uninjured players.

Study Design

Cohort study; Level of evidence, 3.

Methods

Professional soccer players suffering ACJ separation injuries between 1999 and 2018 were identified and were matched to uninjured players (2 controls to 1 injured player) by position, height, age, season year, and length of time played. Information on date of injury, timing to RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) were collected from transfermarkt.co.uk, uefa.com, fifa.com, official team websites, public injury reports, and press releases. Change in performance metrics for the 4 seasons after the season of injury were based on metrics 1 season before injury. Univariate comparisons were performed using independent 2-group t tests and Wilcoxon rank-sum tests when normality of distributions was violated.

Results

A total 59 soccer players with ACJ separation injuries were identified. Mean age at injury was 24.6 ± 5.3 years. Of these, 81% of the players returned to play, with 69% returning within postinjury season 1. Mean time to RTP was 49.8 ± 24.3 days (5.9 ± 4.1 games). Two players suffered recurrent ACJ separation injuries in their professional soccer careers. There were no significant differences between athletes who sustained ACJ injuries versus control athletes in the number of games played, minutes per game per season, goals scored, assists, or points in the 4 seasons after injury. Defenders played fewer minutes and recorded fewer assists during postinjury season 1 when compared with control athletes.

Conclusion

Of the 59 elite soccer players who sustained ACJ separation injuries during the study period, 81% returned to elite competition. Performance metrics were similar to preinjury levels and matched, uninjured control players.

Good to Excellent Functional Outcome and High Return to Sports Rate after Operative Treatment of Unstable Lateral Clavicle Fractures: Comparison of Two Coracoclavicular Button Fixation Techniques

Purpose: Operative therapy for unstable lateral clavicle fractures is necessary to reduce the risk of bony non-union. Irritation and restriction during sportive activities due to the implanted materials are a common reason for impaired function and implant removal. The aim of this study was to gain information on functional outcome and time until return to sport (RTS) after surgical treatment of unstable lateral clavicle fractures, comparing two coracoclavicular button techniques. Methods: A retrospective chart review of patients who were consecutively treated for unstable lateral clavicle fractures at our level one trauma center from 2014 to 2018 was conducted. Two different surgical techniques were evaluated and compared. Group 1 was treated using a locking compression plate and knotted DogBone™ Button, while group 2 received an LCP and knotless DogBone™ Button. Functional outcome (ASES (American Shoulder and Elbow Score), Constant-Score, DASH (Disability of Arm, Shoulder and Hand), MSQ (Munich Shoulder Questionnaire) and SPADI (Shoulder Pain and Disability Index) and time until RTS were investigated and compared between both groups, 1 year postoperatively. Results: A total of 56 patients (n = 35 group 1, n = 21 group 2) with a mean age of 45.1 ± 14.6 years met the inclusion criteria. Functional outcome reached good to excellent results (ASES 94.7 ± 9.8, Constant Score 85.1 ± 8.1, DASH 5.5 ± 8.4, MSQ 90.9 ± 7.2, SPADI 96.1 ± 5.7). Implant removal rates were higher in group 1 (48.3% vs. 35.3%) yet without statistical significance (p = 0.122). All patients returned to sports postoperatively with a mean time period until return to sport of 4.6 (3–9) months. Conclusion: Locking compression plating and coracoclavicular fixation using a knotless Dogbone™ technique provides good to excellent functional outcomes, a high and fast rate of return to sport and lower irritation rates compared to the knotted DogBone™ technique.

Conversion to anatomic coracoclavicular ligament reconstruction (ACCR) shows similar clinical outcomes compared to successful non-operative treatment in chronic primary type III to V acromioclavicular joint injuries

PURPOSE

To compare the clinical outcomes of patients who underwent successful nonoperative treatment for type III-V acromioclavicular joint (ACJ) injuries to those who eventually required conversion to anatomic coracoclavicular ligament reconstruction (ACCR) at a minimum 5-year follow-up.

METHODS

Patients with primary, chronic type III-V ACJ injuries who either underwent successful conservative treatment or conversion to ACCR after failing a trail of conservative management between 2003 and 2014 with a minimum 5-year follow-up were included in the study. Clinical outcome measures comprised the American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) score, collected preoperatively and at final visit for the ACCR group. Outcome scores for patients with successful conservative treatment were only collected at final visit. A Self- Assessment Numeric Evaluation (SANE) score was obtained at terminal follow-up for both groups.

RESULTS

Twenty-two patients (mean age: 40.1 ± 15.6 years) with successful nonoperative treatment and twenty-one patients (mean age: 43.6 ± 12.0 years) who required conversion to ACCR were included in the study. At final follow-up, patients with successful non-operative treatment achieved similar ASES (93.0±12.0NonOP vs. 86.1±16.8ACCR), SST (11.2±1.4NonOP vs. 10.7±2.0ACCR) and SANE scores (80.9±19.7NonOPvs. 90.5±14.7ACCR) compared to those who were converted to ACCR. Additionally, patients who underwent conversion to ACCR showed significant improvement in ASES (49.8±18.1pre vs. 86.1±16.8post; Δ36.3±19.7) and SST scores (6.5±3.2prevs. 10.7±2.0post; Δ4.2±4.0) from pre- to postoperative.

CONCLUSION

At a minimum 5-year follow-up, patients with successful non-operative treatment for type III-V ACJ injuries achieved similar clinical outcomes compared to those who were converted to ACCR. In patients with chronic severe ACJ dislocation a trial of conservative treatment may be attempted, astime from injuryto eventual conversion to ACCR had no significant influence on postoperative clinical outcomes.

LEVEL OF EVIDENCE

Level IV.

Comparison of the TightRope system versus hook plate in acute acromioclavicular joint dislocations: a retrospective analysis

This study compared the results of the minimally invasive coracoclavicular (CC) fixation with a single TightRope (MITR) procedure and the hook plate (HP) procedure for acute acromioclavicular (AC) joint dislocation treatment. Sixteen patients with a mean age of 44.9 ± 11 years were treated with the MITR procedure. Nineteen patients with a mean age of 40.2 ± 8.7 years were treated using the HP procedure. Clinical outcomes were evaluated with the Visual Analog Scale (VAS) for pain, Constant–Murley Score (CMS), and University of California at Los Angeles (UCLA) Shoulder score. Vertical displacement of the clavicle with reference to the height of the acromion was measured in standard anteroposterior radiographs. The mean follow-up was 27 months in the MITR group and 30 months in the HP group. No statistically significant differences were found between the MITR group and the HR group in terms of VAS score (0.4 ± 0.6 vs 0.7 ± 0.6, P = 0.138), UCLA Shoulder score (33.9 ± 2.5 vs 33.7 ± 1.5, P = 0.843), or CMS (95.7 ± 7.3 vs 93.7 ± 6.6, P = 0.400). No redislocation was identified in the HP group, while redislocation occurred in 1 of 16 (6.3%) patients in the MITR group. One patient in the HP group (5.3%) had acromial osteolysis, while no acromial osteolysis was found in the MITR group. No other adverse events, such as infections, tunnel widening, fractures, or implant-related complications, were observed. Both procedures provided satisfactory results. The HP procedure provided better reduction, while the MITR procedure provided a slightly lower tendency of pain. Long-term follow-up is needed to investigate the clinical outcomes and radiological outcomes of both groups.

Coracoclavicular Space Widening on Radiographs After Arthroscopic Stabilization With Suspensory Fixation Does Not Affect Athletic Performance

Purpose

To evaluate the effect of the coracoclavicular distance widening in athletes after arthroscopic acromioclavicular (AC) stabilization using a suspensory button fixation device in terms of function, athletic performance, or isokinetic assessment.

Methods

Sixty-eight athletes with a minimum 6-month follow-up after AC stabilization using suspensory button fixation were allocated in 2 groups, the widening group and non-widening group, according to the measured coracoclavicular distance after 6 months from the operation. The assessment was done every 6 months by Subjective Patient Outcome for Return to Sports (SPORTS) score, Athletic Shoulder Outcome Scoring System (ASOSS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, Constant-Murley score (CMS), and the coracoclavicular distance. Isokinetic testing was performed at 24 months postoperatively to evaluate shoulder abduction and external rotation strength.

Results

No statistically significant differences were found between the 2 groups in terms of the DASH, ASOSS, SPORTS, and the CMS, in addition to the isokinetic testing (P > .05). A statistically significant improvement in both groups over the follow-up stage was identified in the DASH, ASOSS, SPORTS, and the CMS (P < .05).

Conclusions

Coracoclavicular distance widening following arthroscopic suspensory button fixation for AC joint dislocation did not affect function, athletic performance, or isokinetic evaluation in athletes.

Level of Evidence

III; nonrandomized, comparative trial.

Young men in sports are at highest risk of acromioclavicular joint injuries: a prospective cohort study

PURPOSE

To study the incidence of acromioclavicular joint injuries in a general population.

METHODS

All acute shoulder injuries admitted to an orthopaedic emergency department were registered prospectively, using electronic patient records and a patient-reported questionnaire. The regional area was the city of Oslo with 632,990 inhabitants. Patients with symptoms from the acromioclavicular joint without fracture were registered as a dislocation (type II-VI) if the radiologist described widening of the joint space or coracoclavicular distance on standard anteroposterior radiographs. Patients without such findings were diagnosed as sprains (type I).

RESULTS

Acromioclavicular joint injuries constituted 11% of all shoulder injuries (287 of 2650). The incidence was 45 per 10⁵ person-years (95% confidence interval [CI] 40-51). 196 (68%) were diagnosed as sprains and 91 (32%) as dislocations. Median age of all acromioclavicular joint injuries was 32 years (interquartile range 24-44), and 82% were men. Thirty percent of all acromioclavicular joint injuries were registered in men in their twenties. Sports injuries accounted for 53%, compared to 27% in other shoulder injuries [OR 3.1 (95% CI 2.4-4.0; p < 0.001)]. The most common sports associated with acromioclavicular joint injuries were football (24%), cycling (16%), martial arts (11%), alpine skiing and snowboarding (both 9%), and ice hockey (6%).

CONCLUSION

Our study suggests that in the general population, one in ten shoulder injuries involves the acromioclavicular joint and young men in sports are at highest risk. A prognostic level II cohort study.

Editorial Commentary: Coracoclavicular Ligament Reconstruction. Double Up It Is?

More than 100 surgical techniques have been described for the reconstruction of the coracoclavicular ligament complex. None of the techniques appears superior, but double-button fixation for acute high-grade acromioclavicular dislocations has become an attractive option. The clinical outcomes are good to excellent, and the return to physical activity and sport is above 90%. However, complications such as loss of reduction and tunnel widening have been described and can reach up to 80%. The load to failure of the native coracoclavicular complex is more than 600 N, and any surgical technique must surpass this figure. Single-button and loop techniques do not always sufficiently stabilize the acromioclavicular joint. Even double- and triple-button techniques may not restore vertical and horizontal stability of the acromioclavicular joint to its native normal state. Double-button technique restores both scapula and clavicular rotation closest to the native state, but still has lower stiffness and results in higher superior-inferior translation, which could cause ongoing vertical instability.