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

Clinical and radiographic outcomes following anatomic coracoclavicular ligament reconstruction using 4-strand taped suspensory fixation in an active-duty military population

Background

Acromioclavicular (AC) joint injuries are common in young, active populations. However, there is a paucity of literature reporting surgical outcomes following the treatment of AC joint injuries in the military population. Therefore, the purpose of this study was to evaluate the clinical and radiographic outcomes of active-duty military members who underwent arthroscopic-assisted anatomic coracoclavicular ligament reconstruction using a 4-strand suspensory fixation with taped sutures for treatment of high-grade AC joint injuries with a minimum 1-year follow-up.

Methods

A retrospective review was performed on all patients with Rockwood grade IIIB-V AC joint separations who underwent anatomic coracoclavicular ligament reconstruction using a 4-strand suspensory fixation with taped sutures at a single military treatment facility between January 2015 and May 2022. Clinical outcome measures included the Single-Assessment Numerical Evaluation (SANE) score and patient satisfaction using the Likert Scale. Radiographic outcomes were measured by classifying the amount of residual AC joint separation on postoperative radiographs utilizing the Rockwood classification.

Results

Coracoclavicular ligament reconstruction a using 4-strand suspensory fixation with taped sutures was performed in 15 consecutive patients, all of which were active-duty military males with a mean age of 35.8 years. Preoperatively, there were 10 patients with grade IIIB injuries, 1 patient with a grade IV injury, and 4 patients with grade V injuries. The average preoperative SANE score was 40.0. The average length of time from injury to surgery was 46.5 weeks. Patient-reported outcomes were available for 12 of the 15 patients (80%) at an average of 4.9 years postoperatively with an average postoperative SANE score of 77.1 (P = .0002); 11 of these 12 patients (92%) reported they were either satisfied or extremely satisfied with the outcome of the surgery. Postoperative radiographs were available for 14 of the 15 patients (93%) at an average of 2.7 years postoperatively revealing 13 patients had maintained grade I reduction while 1 patient had a grade III separation.

Conclusion

Coracoclavicular ligament reconstruction a using 4-strand suspensory fixation with taped sutures resulted in significantly improved radiographic and patient-reported outcomes in this retrospective review of active-duty military members with grade IIIB-V AC joint separations.

Surgeons consider Rockwood classification the most important factor for decision-making in acute, high-grade acromioclavicular dislocations

Purpose

The aim of this study is to investigate the influence of patient-specific factors, including age, lifestyle considerations as well as the extent of injury according to the Rockwood classification (RW), on the surgeon's decision-making in the choice between operative and nonoperative treatment for acute, high-grade acromioclavicular (AC) joint dislocations.

Methods

Orthopaedic and trauma surgeons were requested to complete an online questionnaire consisting of closed and open questions regarding the treatment of acute, high-grade AC joint dislocations and 24 fictive clinical scenarios.

Results

A total of 133 answered questionnaires were collected. 27 different nationalities from five continents were represented. The included participants had a median experience of 12 years (interquartile range: 2-41). Overall, the treatment option for surgery (answer: YES) was chosen in 2426 answers (76% of cases) compared to 'NO' in 766 (24% of cases). RW classification was considered the most important factor influencing surgical decision-making for most surgeons (69%). Two thirds of the participants answered that smoking does not impact their decision towards surgery and as to the influence of body mass index (BMI) on decision-making, half of the respondents would not alter their preferred treatment based on BMI. Finally, there were no significant differences in decision-making regarding the influence of the participant's demographics.

Conclusion

This study highlights that RW classification is the most important factor to consider in the surgeon's decision-making between operative and nonoperative treatment in acute, high-grade AC joint dislocations. Participants preferred operative treatment over nonoperative treatment in acute, high-grade AC joint dislocation in 76% of case scenarios, increasing up to 90% when RW Grade III lesions were not taken into account. These findings contrast with recent studies reporting good functional outcomes of conservatively treated acute, high-grade AC injuries and highlight the need to bridge the gap between evidence and practice.

Level of Evidence

Level V.

A bibliometric analysis of the top 50 cited studies related to acromioclavicular joint instability

Background

Acromioclavicular joint (ACJ) injury is a common orthopaedic condition accounting for over 40 % of all shoulder injuries. The purpose of this study is to assess the research trends and characteristics of the top 50 cited articles on ACJ instability.

Methods

A systematic search was conducted in Web of Science to identify articles primarily related to ACJ injury or instability. Characteristics including citation number, country of origin, journal and institution of publication, impact factor, authorship, level of evidence, patient demographics, and study type were analyzed and recorded.

Results

Research output on ACJ instability has been steadily increasing, with the top 50 cited studies predominantly presenting Level IV evidence. These studies primarily focused on treatment outcomes which included predominantly male patients and exhibited a large variation in citation counts. The American Journal of Sports Medicine was the most productive journal, and the USA was the most productive nation.

Conclusion

There is an increasing number of publications in the ACJ instability literature, primarily concentrated in a few institutions and journals, and focusing mainly on treatment outcomes. A significant portion of these publications are of low scientific quality, and there is a notable lack of research on outcomes for females.

Patient-reported, clinical and radiological factors associated with the result after non-surgical management of acute AC joint dislocation Rockwood type III and V

PURPOSE

The treatment of Rockwood type III and V acromioclavicular (AC) joint dislocations is controversial, and an individualized treatment algorithm is yet to be developed. The objective of this study was to investigate the association of demographical, clinical, patient-reported and radiological variables with the Western Ontario Shoulder Instability Index (WOSI) score and risk of surgery.

METHODS

Inclusion criteria for this prospective cohort study were patients aged 18-60 with an acute AC joint dislocation with >25% increase in the coracoclavicular distance on bilateral Zanca radiographs. Patients were treated non-surgically with 3 months of home-based training and the option of delayed surgical intervention. The outcomes were the WOSI score and surgery yes/no. Demographical, clinical, patient-reported (WOSI and Shoulder Pain and Disability Index [SPADI]) and radiological variables were collected at baseline and 6 weeks after the injury and investigated for association with the outcomes at 3 months, 6 months and 1 year.

RESULTS

Ninety-five patients with Rockwood type III/V AC joint dislocation were included. Pre-injury participation in overhead/collision sports was a risk factor for surgery with an odds ratio of 5 (p = 0.03). Reduced range of motion (ROM) at baseline was associated with reduced WOSI scores and increased risk of surgery. At 6 weeks, reduced ROM, increased SPADI and increased pain during cross-over were associated with the outcomes. Radiological measurements were not correlated with the result. At the 6 weeks follow-up, patients eventually requiring surgery could be detected with a sensitivity of 100% and a specificity of 94% based on a SPADI score of >30 and a ROM ≤ 140° in shoulder flexion or abduction.

CONCLUSION

ROM was the only variable consistently associated with both WOSI and risk of surgery. Six weeks after the injury, it was possible to detect patients in need of surgery based on ROM and SPADI with a sensitivity of 100% and a specificity of 94%.

LEVEL OF EVIDENCE

Level II.

The Effect of Clavicular Tunnel Position on Reduction Loss in Patients with Acute Acromioclavicular Joint Dislocations Operated with a Single-Bundle Suspensory Loop Device

OBJECTIVE

The treatment of acromioclavicular joint (ACJ) dislocations offers numerous options, and ongoing debates persist regarding their comparative effectiveness. Among these options, the suspensory loop device (SLD) is one of the most favored treatment modalities. Despite the observed high reduction loss rate associated with SLD, the treatment yields favorable clinical outcomes. This study aimed to investigate the clinical outcomes of patients with acute type 3 and 5 ACJ dislocations who underwent open and arthroscopic procedures using a single-bundle SLD, and to evaluate the effect of clavicular tunnel position on reduction loss.

METHODS

Thirty-seven eligible patients diagnosed with acute type 3 and type 5 ACJ dislocation who underwent open and arthroscopic surgery with a single-bundle SLD between January 2015 and March 2022 were evaluated retrospectively. Demographic data and radiological measurements including coracoclavicular (CC) interval, clavicle length (CL), and implant distance (ID) were recorded. The ID/CL ratio was calculated and a value between 0.17 and 0.24 was considered as "acceptable implant position". Reduction loss and other complications were noted. Patients were divided into two groups: open (Group 1) and arthroscopic (Group 2). Constant Murray Score (CMS) and Visual Analog Scale (VAS) were used for clinical and functional outcomes. Non-parametric tests were used for statistical analysis of variables.

RESULTS

The study included six females (16.2%) and 31 males (83.8%) with a mean age of 40.2 ± 14.7 years (range: 20-75). The mean follow-up period was 22.3 ± 16.7 months (range: 6-72). The average time from trauma to surgery was 6.3 ± 5.3 days (range: 1-18). At the last follow-up, the CMS was 89.3 ± 8.8 and the VAS score was 2.1 ± 0.9. The mean ID/CL ratio was 0.19 ± 0.1 and 19 patients (51.4%) were between 0.17 and 0.24. Reduction loss was observed in nine patients (24.3%). There were no significant differences between Group 1 and Group 2 regarding operation time (p = 0.998), ID/CL ratio (p = 0.442), reduction loss (p = 0.458), CMS (p = 0.325), and VAS score (p = 0.699). Of the 28 patients without reduction loss, 16 had an ID/CL ratio between 0.17 and 0.24 (p = 0.43). Furthermore, within the 0.17-0.24 interval, CMS was higher with an average of 91.8 ± 5.1 compared to the other intervals (p = 0.559).

CONCLUSION

The clinical and functional outcomes of acute type 3 and type 5 ACJ dislocation operated open and arthroscopically with single-bundle SLD are similar and satisfactory. A clavicular tunnel position in the range of 0.17-0.24 (ID/CL ratio) is recommended to maintain postoperative reduction.

A Self-Designed Endobutton Installation Device for Coracoclavicular Stabilization in Acute Rockwood Type III Acromioclavicular Joint Dislocation

OBJECTIVE

Endobutton technique could provide flexible coracoclavicular (CC) stabilization for acromioclavicular joint (ACJ) dislocation and achieved good clinical outcomes. However, the difficult part of this technique was placement of the Endobutton to the coracoid base. In this study, we designed an Endobutton installation device to place the Endobutton at the coracoid base. And we examined the clinical and radiographic outcomes of patients with acute Rockwood type III ACJ dislocation repaired with Endobutton using this device.

METHODS

We designed an Endobutton installation device to place the Endobutton at the coracoid base to achieve CC stabilization. We retrospectively reviewed 42 patients with acute Rockwood type III ACJ dislocation who underwent CC stabilization with Endobuttons placed either using this novel device (group I, n = 19) or the traditional technique (CC stabilization without using special device, group II, n = 23) from January 2015 to April 2020. The two groups were compared regarding the operative time, intraoperative blood loss, and clinical and radiologic outcomes at final follow-up. The operation-related complications were also evaluated. The Student's t test and the Mann-Whitney U-test were used to compare differences in continuous variables. Differences in categorical variables were assessed with either the Pearson's chi-squared test or Fisher's exact test.

RESULTS

Forty-two patients were clinically followed up for a minimum of 12 months. Compared with group II, group I had a significantly shorter mean operative time (56.05 ± 7.82 min vs. 65.87 ± 7.43 min, p < 0.01) and significantly lesser mean intraoperative blood loss (67.89 ± 14.75 mL vs. 94.78 ± 25.01 mL, p < 0.01). At final follow-up, there were no significant differences between the two groups in the visual analog scale score for pain, Oxford Shoulder Score, Disabilities of the Arm, Shoulder, and Hand score, and postoperative CC distance of the affected side. Loss of reduction occurred in four patients in group I and three patients in group II (p = 0.68); there were no other operation-related complications in either group.

CONCLUSIONS

The Endobutton installation device makes placement of the Endobutton at the coracoid base easier and achieves satisfactory clinical and radiologic outcomes without additional complications in acute Rockwood type III ACJ dislocation.

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Rockwood type III is the most common type of acromioclavicular joint dislocation: A prospective cohort study investigating the incidence and epidemiology of acute acromioclavicular joint dislocations in an urban population

Introduction

Acromioclavicular (AC) joint dislocations are common, but basic epidemiological features and sub-classification are not well investigated. The aim of the study was to investigate the incidence and epidemiology of acute AC joint dislocations in the capital region of Denmark.

Methods

All patients with acute AC joint dislocation admitted to the emergency departments at 3 University Hospitals serving a population of 549,225 residents were prospectively registered from January to December 2019. Patients with trauma to the shoulder, pain from the AC joint and increased coracoclavicular distance on radiographs were included and classified according to Rockwood's classification. Data on age, sex and mechanism of injury were registered.

Results

A total of 106 patients, male:female ratio 8.6:1, were included. Rockwood type III was most common accounting for 59/106(55.7%) of the injuries. The incidence was 19.3 per 100,000 person-years at risk (PYRS). The age distribution was bimodal peaking at the ages of 20-24 and 55-59 years. The most common mechanism of injury was sports, 80/106, with cycling accounting for 51/106.

Discussion/Conclusion

Rockwood type III was the most common type of AC joint dislocation constituting 55.7% of the injuries. The incidence was 19.3 per 100,000 PYRS. Young and middle-aged males were at highest risk and most injuries occurred during sports.

Acromioclavicular Joint Injuries in Sport

ABSTRACT

Sport-related shoulder injuries, including disruptions to the acromioclavicular joint (ACJ), are common. An ACJ injury is classified by the degree and direction of the clavicle displacement. Although the diagnosis can be made clinically, standard radiographic views are important to determine the severity of the ACJ disruption and assess for concurrent injuries. The majority of ACJ injuries can be managed nonoperatively; however, surgical treatment is indicated in some cases. Long-term outcomes are generally favorable for most ACJ injuries, and athletes generally return to sport without functional limitations. This article provides an in-depth discussion regarding all aspects of ACJ injuries, including clinically relevant anatomy, biomechanics, evaluation, treatment, and complications.

Novel Orthobiologic Preparation and Regenerative Rehabilitation of a Complex Shoulder Injury in a Competitive Adolescent Female Athlete

Background

Platelet-rich plasma (PRP) and prolotherapy have resulted in promising outcomes in patients with various types of shoulder injuries. However, there is a lack of preliminary evidence supporting preparation of PRP production, timely application of these therapies and regenerative rehabilitation protocols. The purpose of this case report is to describe the distinct method including orthobiologic preparation, tissue-specific treatment and regenerative rehabilitation of an athlete with a complex shoulder injury.

Case Presentation

A 15y/o competitive female wrestler with a complex shoulder injury presented to the clinic after unsuccessful conservative rehabilitation. Unique methods were incorporated to optimize PRP production, specific tissue healing and regenerative rehabilitation. Multiple injuries required different orthobiologic interventions at different time frames, in order to promote optimal healing and stability of the shoulder.

Outcomes

The described interventions resulted in successful outcomes including pain, disability, full return to sport, and regenerative tissue healing confirmed with diagnostic imaging.

Level of Evidence

5.

ANALYSIS OF JOINT INJURIES AND MOVEMENT SKILLS IN COLLEGE BASKETBALL

ABSTRACT Introduction: Reducing the risk of joint injuries is especially important in combative contact sports such as basketball. Objective: Analyze the joint injuries of college basketball students and outline methods of improving sports skills to prevent sports injuries. Methods: The experimental group used a specific training for basketball skills training and knee joint recovery. The control group remained in ordinary basketball training, lasting 60 minutes, thrice a week for eight weeks. Results: The experimental group increased their squat level from 1.83 to 2.14 after the experiment; in terms of hurdles, there was a change from 2.09 to 2.62, the experimental group increased from 1.37 to 2.48, and in terms of active lower limb lifting, the experimental group increased from 2.19 to 2.72 after the test. Conclusion: The training presented showed a clear effect on the recovery of knee joint function and improvement in the competitive level of college basketball athletes. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

Acromioclavicular and coracoclavicular ligamentous insertion distances depend on the scapular tilt and decrease with anterior direction of the inferior scapula angle

PURPOSE

A variety of reconstruction techniques exist for the operative treatment of a ruptured acromioclavicular and coracoclavicular ligamentous complex. However, the complication rate remains high; between 5 and 89%. The intraoperative distance between the clavicle, acromion and coracoid is important for the refixation quality. In this study, the influence of scapular deflection on coracoclavicular and acromioclavicular distances was analysed.

METHODS

The ligamentous insertions of 24 fresh-frozen human scapulae were exposed. The coracoclavicular and acromioclavicular ligaments were referenced and captured in a rigid body system using a three-dimensional (3D) measurement arm. The inferior angle of the scapula was manually pulled into maximum anterior and posterior deflection, simulating a patient positioning with or without dorsal scapular support, respectively. Based on the rigid body system, the distances between the ligamentous insertions were calculated. Statistical evaluation was performed by setting the distances in anterior deflection to 100% and considering the other distances relative to this position.

RESULTS

The scapular deflection had a considerable impact on the distance between the ligamentous insertions. Concerning the conoid ligament, the mean distance was almost doubled when the inferior angle pointed posteriorly compared to anterior deflection (195.3 vs 100.0%; p = 0.028). The insertion of the acromioclavicular capsule also showed a significant association with the direction of deflection (posterior = 116.1% vs. anterior = 100%; p = 0.008).

CONCLUSION

Dorsal support shifting the inferior angle of the scapula anteriorly reduces the distance between the ligamentous insertions. Therefore, a patient position on a shoulder table with posterior support of the scapula is recommended to reliability reduce the acromioclavicular joint.

National incidence of joint dislocation in China: a retrospective survey of 512,187 individuals

BACKGROUND

Joint dislocations significantly impact public health. However, a comprehensive study on the incidence, distribution, and risk factors for joint dislocations in China is lacking. We conducted the China National Joint Dislocation Study, which is a part of the China National Fracture Study conducted to obtain the national incidence and risk factors for traumatic fractures, and to investigate the incidence and risk factors for joint dislocations.

METHODS

For this national retrospective epidemiological study, 512,187 participants were recruited using stratified random sampling and probability-proportional-to-size method from January 19 to May 16, 2015. Participants who sustained joint dislocations of the trunk, arms, or legs (skull, sternum, and ribs being excluded) in 2014 were personally interviewed to obtain data on age, educational background, ethnic origin, occupation, geographic region, and urbanization degree. The joint-dislocation incidence was calculated based on age, sex, body site, and demographic factors. The risk factors for different groups were examined using multiple logistic regression.

RESULTS

One hundred and nineteen participants sustained 121 joint dislocations in 2014. The population-weighted incidence rate of joint dislocations of the trunk, arms, or legs was 0.22 (95% confidence interval [CI]: 0.16, 0.27) per 1000 population in 2014 (men, 0.27 [0.20, 0.34]; women, 0.16 [0.10, 0.23]). For all ages, previous dislocation history (male: OR 42.33, 95% confidence interval [CI]: 12.03-148.90; female: OR 54.43, 95% CI: 17.37-170.50) and alcohol consumption (male: OR 3.50, 95% CI: 1.49-8.22; female: OR 2.65, 95% CI: 1.08-6.50) were risk factors for joint dislocation. Sleeping less than 7 h/day was a risk factor for men. Compared with children, women aged ≥15 years (female 15-64 years: OR 0.16, 95% CI: 0.04-0.61; female ≥65 years: OR 0.06, 95% CI: 0.01-0.41) were less likely to sustain joint dislocations. Women with more than three children were at higher dislocation risk than women without children (OR 6.92, 95% CI: 1.18-40.78).

CONCLUSIONS

The up-to-date data on joint dislocation incidence, distribution, and risk factors can be used as a reference for national healthcare, prevention, and management in China. Specific strategies for decreasing alcohol consumption and encouraging adequate sleeping hours should be developed to prevent or reduce dislocation incidents.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-EPR-15005878.

Hybrid coracoclavicular and acromioclavicular reconstruction in chronic acromioclavicular joint dislocations yields good functional and radiographic results

PURPOSE

Optimal treatment of chronic unstable acromioclavicular (AC) joint dislocations (stage 3-5 according the Rockwood classification) is still debated. Anatomic coracoclavicular (CC) reconstruction is a reliable option in terms of two-dimensional radiographic reduction, clinical outcomes, and return to sports, but there remain concerns regarding anterior-posterior stability of the AC joint with CC ligament reconstruction alone. The aim of the present study was to describe the mid-term results of a new hybrid technique with CC and AC ligament reconstruction for chronic AC joint dislocations.

METHODS

Twenty-two patients surgically treated for chronic AC joint dislocations (grade 3 to 5) were retrospectively reviewed. All patients were assessed before surgery and at final follow-up with the Constant-Murley score (CMS) and the American Shoulder and Elbow Surgeons (ASES) score. The CC vertical distance (CCD) and the CCD ratio (affected side compared to unaffected side) were measured on Zanca radiographs preoperatively, at 6 months postop and at final follow-up. The same surgical technique consisting in a primary fixation with a suspensory system, coracoclavicular ligaments reconstruction with a double loop of autologous gracilis and acromioclavicular ligaments reconstruction with autologous coracoacromial ligament was performed in all cases.

RESULTS

Twenty-two shoulders in 22 patients (19 males and 3 females) were evaluated with a mean age of 34.4 ± 9 years at the time of surgery. The mean interval between the injury and surgery was 53.4 ± 36.7 days. The mean duration of postoperative follow-up was 49.9 ± 11.8 months. According to the Rockwood classification, there were 5 (22.6%) type-III and 17 (77.2%) type-V dislocations. Mean preoperative ASES and CMS were 54.4 ± 7.6 and 64.6 ± 7.2, respectively. They improved to 91.8 ± 2.3 (p = 0.0001) and 95.2 ± 3.1 (p = 0.0001), respectively at final FU. The mean preoperative CCD was 22.4 ± 3.2 mm while the mean CCD ratio was 2.1 ± 0.1. At final FU, the mean CCD was 11.9 ± 1.4 mm (p = 0.002) and the mean CCD ratio was 1.1 ± 0.1 (p = 0.009). No recurrence of instability was observed. One patient developed a local infection and four patients referred some shoulder discomfort. Heterotopic ossifications were observed in three patients.

CONCLUSIONS

The optimal treatment of chronic high-grade AC joint dislocations requires superior-inferior and anterior-posterior stability to ensure good clinical outcomes and return to overhead activities or sports. The present hybrid technique of AC and CC ligaments reconstruction showed good clinical and radiographic results and is a reliable an alternative to other reported techniques.

LEVEL OF EVIDENCE

Level IV.

Single tunnel technique versus coracoid sling technique for arthroscopic treatment of acute acromioclavicular joint dislocation

To evaluate and compare the efficacy of two techniques for the treatment of acute acromioclavicular joint dislocation, the charts of 60 patients diagnosed with acute Rockwood type IV and V acromioclavicular joint dislocation that undergone arthroscopic fixation procedure with single tunnel technique (N = 30, 30.7 ± 5.7 years old) or coracoid sling technique (N = 30, 30.1 ± 5.4 years old) fixation were retrospectively reviewed. The Visual Analog Scale pain score, Constant shoulder functionality score, Karlsson acromioclavicular joint score, the time of return to sports and activity, and plain radiographs of the affected shoulder at different time points of follow-up were recorded for a minimum of 2 years post-op. The majority of the patients recovered to their preoperative activity levels with few complications. The average postoperative acromioclavicular and coracoclavicular distances were significantly narrower than preoperative measurements in both groups without significant difference between the two groups at 2 years post-op (P < 0.05). The coracoid sling technique group had reduced operative time, shorter time of recovery of shoulder movements, higher Constant functionality scores and Karlsson acromioclavicular joint scores, and fewer complications than the single tunnel technique group at the last follow-up (P < 0.05). Therefore, coracoid sling technique achieved superior clinical outcomes with fewer complications compared to the traditional single tunnel technique in arthroscopic treatment of acute acromioclavicular joint dislocation.

Acromioclavicular Disk as a Potential Source of Pain in AC Joint Injuries

BACKGROUND

Injuries of the acromioclavicular joint (ACJ) are common shoulder injuries that often lead to pain and dysfunction of the affected shoulder. Regardless of operative or nonoperative treatment, a relatively large number of patients remain symptomatic and experience pain. However, the specific source of persistent pain in the ACJ remains ambiguous.

PURPOSE

To investigate the presence of sensory nerve fibers or pain-generating neurotransmitters within the intra-articular disk of the ACJ to determine its potential role as an independent pain generator in ACJ disorders.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Twelve paired ACJs from 6 fresh human cadavers (mean age, 56 years; range, 41-82 years) were harvested and freed from surrounding soft tissues, leaving only the ACJ capsule intact. The specimens were placed in 4.5% formaldehyde fixative for a minimum of 48 hours. Coronal plane sections were obtained and demineralized in EDTA for a week, embedded in paraffin for 12 hours, and dehydrated overnight. With a rotation microtome, 2-μm sections were cut and stained with hematoxylin and eosin to investigate tissue architecture and confirm the presence of a fibrocartilaginous intra-articular disk. The sections were immunohistochemically stained with antisera against S100, neuropeptide Y (NPY), and substance P (SP) to detect for neural tissue. Additionally, a nerve fiber count per 10 high-power fields representing an area of 0.2 mm² was conducted for S100 stains. All sections were examined for the presence of positive immunoreactivity to S100, NPY, and SP.

RESULTS

The presence of a fibrocartilaginous intra-articular disk could be observed in all 12 examined ACJs. In all specimens, an immunoreactivity to S100, NPY, and SP could be observed within the superior peripheral region of the intra-articular disk. High-power field nerve counts of the S100 stains revealed a mean ± SD of 7.9 ± 2.28 nerves per 10 high-power fields (range, 4-12).

CONCLUSION

The documented immunoreactivity to S100, NPY, and SP indicates the presence of somatic and autonomic nerve fibers within the intra-articular disk of the ACJ.

CLINICAL RELEVANCE

Confirming the presence of nerve fibers within the intra-articular disk of the ACJ suggests that the disk itself could be an independent source of pain after injury and thus a possible explanation for recalcitrant pain after treatment.

Nonanatomic and Suture-Based Coracoclavicular Joint Stabilization Techniques Provide Adequate Stability at a Lower Cost of Implants in Biomechanical Studies When Compared With Anatomic Techniques: A Systematic Review and Meta-Analysis

Purpose

To compare the stability and cost of the used implants in nonanatomic and anatomic acromioclavicular joint repair/reconstruction (ACCR) techniques tested in cadaveric shoulder biomechanical studies during the last decade.

Methods

A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and prospectively registered in PROSPERO. Two independent reviewers searched PubMed, Embase, and Virtual Health Library databases. Studies evaluating 3-direction stability under 70-N loads and load-to-failure protocols with servohydraulic testing systems were included. A meta-analysis of the mean differences of anterior, posterior, and superior direction; relative stability value in 3 directions; superior direction load-to-failure; stability/cost index; and load-to-failure/cost index was performed using a continuous random-effects model and 95% confidence interval.

Results

Eighteen articles were included. Both non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and load-to-failure. ACCR techniques were biomechanically better in terms of anterior stability (P = .04) and relative stability value (mean difference 64.08%, P = .015). However, supraphysiological stability and failure loads were achieved with non-ACCR techniques at a lower cost of implants. Techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes had the greatest stability/cost index and load-to-failure/cost index among the included techniques (confidence interval 99%).

Conclusions

Non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and failure loads in controlled biomechanical testing. However, non-ACCR and techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes provide supraphysiologic stability and failure loads at a lower cost of implants.

Clinical Relevance

Non-ACCR and suture-based techniques may provide more cost-effective and greater value treatment for acromioclavicular joint injury and could be considered in the surgical management of normal activity individuals and cost-sensitive populations.

The strategies of perioperative management in orthopedic department during the pandemic of COVID-19

Background

Coronavirus disease 2019 (COVID-19) has broken out and spread rapidly nationwide at the beginning of 2020, which has brought huge impacts to people and work. The current situation of prevention and control is severe and urges guidance for clinicians, especially for medical systems. In the hope of providing a reference and recommendation for the prevention and control of the COVID-19, we carried out research to improve the quality of patient care and prevention during this epidemic.

Methods

All of the staff were trained rapidly to master personal protection in our department. We reviewed the patients’ discharged records who underwent surgery in our department during January 1 to March 1, 2019, and January 1 to March 1, 2020. The management of the surgery patients and flow charts were described and analyzed. Post-operation outcomes of the patients include duration, complications, surgical site infection (SSI), system infection, re-operation, and mortality. Both chi-squared test and Student’s t test were performed to determine the relationship between the two periods in terms of post-operation outcomes.

Results

Descriptive statistics analysis revealed that demographic of the patients between the two periods is similar. We had benefited from the strict flowcharts, smart robot, and protection equipment during the perioperative managements for orthopedic patients. With the help of the strict flow charts and smart equipment, post-operation outcomes of the patients revealed that the rates of the complications and re-operation had been reduced significantly (p < 0.05), while duration of operation, SSI, and system infection had no significant difference between two periods (p > 0.05). No patient and staff caught COVID-19 infection or mortality during the epidemic.

Conclusions

Our study indicated that medical quality and efficiency were affected little with the help of strategies described above during the epidemic, which could be a reference tool for medical staff in routine clinical practice for admission of patients around the world. What is more, the provided strategies, which may evolve over time, could be used as empirical guidance and reference for orthopedic peers to get through the pandemic and ensure the normal operation of the hospital.