Hook plate fixation for acute acromioclavicular dislocations without coracoclavicular ligament reconstruction: a functional outcome study in military personnel

Surgical management of acute, high-grade acromioclavicular joint separations: a systematic review

Background

While a number of treatment options exist for repair of acute, high-grade acromioclavicular joint (ACJ) separation, none have emerged as the standard of care. The purpose of this study was to systematically review the literature on surgical treatment of acute, high-grade (Rockwood grades III-V) ACJ separations in order to compare outcomes between direct fixation and tendon graft ligament reconstruction.

Methods

A systematic review of the literature evaluating outcomes for acute ACJ separation treatment with direct fixation or free biologic tendon graft reconstruction was performed. The following databases were examined: the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2021), and Embase (1980-2021). Studies were included if they reported a mean time to surgery as <6 weeks, contained >10 patients with a minimum 1-year follow-up, and reported clinical or radiographic outcomes.

Results

A total of 52 studies met the inclusion criteria. Seven studies reported outcomes following tendon graft ligament reconstruction (n = 128 patients). There were multiple methods of direct fixation. Thirty-three studies utilized suture button constructs (n = 1138), 16 studies used hook plates (n = 567), 2 studies used coracoclavicular screws (n = 94), 2 studies used suture fixation (n = 93), 2 studies used suture anchor (n = 55), 2 studies used suture cerclage fixation (n = 87), 1 used single multistrand titanium cable (n = 24), and 1 used K wire (n = 11). The mean follow-up Constant scores ranged from 77.5 to 97.1 in the fixation group compared to 90.3-96.6 in the tendon graft group. The mean visual analog scale scores ranged from 0 to 4.5 in the fixation group and 0.1-1 in the tendon graft group. Net CC distance ranged from 17.5 to 3.6 mm in the fixation group and 7.4-4 mm in the tendon graft group. The revision rates ranged from 0.0% to 18.18% in the direct fixation group and 5.88%-17% in the tendon graft group.

Conclusion

Direct fixation and tendon graft reconstruction for management of acute, high-grade ACJ separations have similar patient subjective and radiographic outcomes, as well as complication and revision rates at a minimum 1-year follow-up.

Clavicular hook plate for acute high-grade acromioclavicular dislocation involving Rockwood type V: clinical and radiological outcomes and complications evaluation

Background

The surgical treatment of high-grade acromioclavicular joint dislocation remains a matter of debate. Clavicular hook plate internal fixation was widely used in the treatment of acromioclavicular dislocation because of its easy-to-master surgical technique. This study aimed to evaluate outcomes using hook plate fixation for acromioclavicular dislocation.

Methods

A consecutive series of 57 patients with acute acromioclavicular joint dislocation involving Rockwood type V were treated between November 2013 and September 2019 using hook plate fixation. The functional outcomes (using the visual analogue score, Constant-Murley score, and University of California Los Angeles score), the quality of surgical reduction (using the coracoclavicular distance), and post-operative complications were assessed with about 46 months of follow-up.

Results

The mean Constant-Murley score increased from 72.6 before surgery to 87.6 at final follow-up. The mean University of California Los Angeles score was 14.1 pre-operatively and 31.6 at final follow-up. Meanwhile, the visual analogue scores were significantly reduced from 3.4 pre-operatively to 1.3 post-operatively. The coracoclavicular distance decreased from 19.4 mm pre-operatively to 10.9 mm at the last follow-up. Post-operative functional and radiological outcomes were significantly improved compared with pre-operative outcomes (P < 0.01). The overall excellent and good result was 35.1% (20/57) and 54.1% (31/57), respectively. At follow-up, the overall complication rate was 15.8% (9/57) including subacromial impingement (three patients), acromial osteolysis (three patients), reduction loss (one patient), acromioclavicular joint osteoarthritis (one patient), and calcification (one patient).

Conclusion

Hook plate fixation was a viable treatment approach, and achieved good clinical outcomes in the treatment of acute acromioclavicular dislocation involving V. But some complications of hook plate fixation should not be ignored.

Biomechanical effects of different numbers and locations of screw-in clavicle hook plates

Purpose: We sought to analyze the biomechanical effects which both different numbers and locations of screws have on three different clavicle hook plates, as well as any possible causes of sub-acromial bone erosion and peri-implant clavicular fractures.

Methods: This study built thirteen groups of finite element models using three different clavicle hook plates (short plates, long plates, and posterior hook offset plates) in varying numbers and locations of the screws. The von Mises stress distribution of the clavicle and hook plate, as well as the reaction force of the acromion was evaluated.

Results: The results show that inserting screws in all available screw holes on the hook plate produces a relatively large reaction force on the acromion, particularly in the axial direction of the bone plate. The fewer the screws implanted into the clavicle hook plate, the larger the area of high-stress distribution there is in the middle of the clavicle, and also, the higher the stress distribution on the clavicle hook plate.

Conclusion: This study provides orthopedic physicians with the biomechanical analysis of different numbers and locations of screws in clavicle hook plates to help minimize surgical complications.

Surgical Management of Acute Rockwood Grade III Acromioclavicular Joint Dislocations: A Systematic Review

Injuries of the acromioclavicular joint (ACJ) occur frequently in young and active people. The best management of acute grade III injuries has been a source of controversy and extensive debate. When surgery is indicated, there is still no gold standard surgical technique for treating acute grade III ACJ injuries.

The methodology of this review was a comprehensive search of PubMed, Medline, Cochrane, and EMBASE databases using various combinations of the keywords “Rockwood,” “type III,” “grade III,” “treatment,” “surgery,” “acromioclavicular joint,” and “dislocation,” since the inception of the databases to December 2020. Surgical techniques were divided into two groups. In group 1 were ACJ fixation techniques using hardware such as the hook plate, Kirschner wires, and wire cerclage; group 2 included coracoclavicular (CC) ligament fixation/reconstruction techniques using double buttons, TightRope®, suture anchors, Endobuttons, the Infinity-Lock^TM Button System, etc. Fourteen studies were selected for the final review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

This review showed better outcome scores in group 2. Overall, complication rates were higher in group 1 compared to group 2. The results of this review show that CC fixation, using suspensory or loop devices, of Rockwood grade III injuries, has better outcomes and fewer complications than fixation of the ACJ with hardware.

Clinical Outcomes of Arthroscopy-Assisted Modified Triple Endobutton Plate Fixation in Rockwood Type III Acute Acromioclavicular Joint Dislocation: A Retrospective Study

Objective

The common triple Endobutton plate (CTEP) fixation is a lengthy procedure that is associated with high failure rates. Therefore, we used arthroscopy to improve the Endobutton fixation method by shortening the duration of surgery and reducing operative complications. This study explored the safety and effectiveness of arthroscopy‐assisted modified triple Endobutton plate (MTEP) fixation in Rockwood type III managing acute acromioclavicular joint (ACJ) dislocation.

Methods

This was a retrospective single‐center study involving 73 patients with Rockwood type III acute ACJ dislocation treated between January 2016 and January 2021. The 73 patients were classified into three groups, the acromioclavicular hook plate (ACHP) group (22 cases), CTEP group (24 cases) and MTEP group (27 cases), based on the type of surgical treatment they received. Clinical outcome data from the patient records, including the Constant–Murley score (CMS), American Shoulder and Elbow Surgeons score (ASES) and University of California at Los Angeles shoulder rating scale score (UCLA), were retrospectively reviewed. The scores were assessed before surgery and at the third and twelfth month after surgery. The clavicle‐coracoid (CC) distance on the affected side was estimated from imaging scans taken before surgery, on the second day after surgery, and within the third and twelfth month after surgery. The student's t‐test was used to compare normally distributed data for independent samples, while homogeneity of variance test was used to compare normally distributed data among multiple groups. Non‐normally distributed data were compared using Mann–Whitney rank‐sum tests.

Results

There were no differences in age, gender, body mass index (BMI), dislocated side, trauma etiology, and duration of follow‐up among the three groups. There was also no significant difference in the duration of surgery between the ACHP and MTEP groups, although the duration in the two groups was shorter than in the CTEP group (P < 0.05). The duration of hospitalization for the MTEP group was significantly shorter than for the CTEP group which was in turn shorter than for the ACHP group (both P < 0.05). There was no significant difference in postoperative CMS, ASES, and UCLA scores between the CTEP and MTEP groups but the score for the two groups differed significantly from those of the ACHP group (all Ps < 0.05). In addition, there was no significant difference in CC distance among the three groups after surgery (P > 0.05).

Conclusion

Arthroscopic reconstruction of the coracoclavicular ligament using MTEP fixation to manage acute Rockwood type III ACJ dislocation is minimally invasive, and is associated with rapid functional recovery, few complications and satisfactory early clinical results.

Managing acute acromioclavicular joint dislocation during COVID 19 pandemic by minimally invasive technique with suture anchor and miniplate: A pilot study

Background

Acromioclavicular (AC) joint dislocation is common in sportsmen and physically active population. Its management depends upon the grade of injury and functional demands of the patient. A variety of surgical procedures have been described with different limitations and advantages. The present study has assessed the clinical and radiological outcome of acute AC joint dislocation managed with a 3.5 mm Titanium suture anchor and 2 mm miniplate construct which requires lesser dissection, surgical time and thus contact with the patient as mandated by COVID-19 pandemic.

Methods

We enrolled 10 patients of Rockwood type-III, IV and V acute AC joint injury (<3 weeks old) reporting at this hospital from Feb 2020 to May 2021. All were tested for COVID-19 using reverse transcriptase polymer chain reaction test (RTPCR) and managed by closed/open reduction and fixation with a 3.5 mm Titanium Suture Anchor and a 2 mm Titanium miniplate construct. Follow-up was done at 3, 6 and 9 month post-operatively.

Results

The average age of patients was 31 yrs. RTPCR test for COVID-19 was negative in all patients. Median surgical time was 25 min (Interquartile Range[IQR] = 16-34 min) and median follow-up duration was 36 weeks (IQR = 33-39 weeks). Median visual analogue scale score and IQR at pre-operative, 3 month, 6 month and 9 month follow-up was 7(IQR = 6-8), 3.5(IQR = 2.5-4.5), 2(IQR = 0) and 1(IQR = 0), respectively. Median constant score at pre-operative, 3 month, 6 month and 9 month follow-up were 34(IQR = 25-43), 65.5(IQR = 60.5-70.5), 82.5(IQR = 77.5-87.5) and 88(IQR = 81-95). There was significant improvement in clinical status (non parametric-Friedman test p < 0.001). Radiographs showed no loss of reduction, fracture or implant failure till last follow-up.

Conclusions

Minimally invasive technique with a 3.5 mm Ti-suture anchor and 2 mm plate is an easy, fast and reliable construct for the management of acute AC dislocation in physically active population.

Does coracoclavicular augmentation additional to hook plate fixation provide benefits in acute unstable acromioclavicular dislocation? A meta-analysis

Background

Acromioclavicular joint (ACJ) dislocation is a common shoulder injury. In treating acute unstable ACJ dislocation, a hook plate (HP) is a straightforward and popular option for ensuring proper reduction and rigid fixation while promoting AC and coracoclavicular (CC) ligament healing. Surgeons typically remove the HP to prevent subacromial impingement and acromial osteolysis; however, concerns about redislocation after implant removal remain. Therefore, additional CC augmentation may be helpful in combination with HP fixation. The aim of this meta-analysis is to compare the outcomes and complications of HP fixation with or without additional CC augmentation for acute unstable ACJ dislocation.

Methods

We searched the PubMed, EMBASE, and Web of Science databases for relevant case–control studies. The primary outcomes were patient-reported outcome measures; the secondary outcomes were pain measured using a visual analog scale (VAS), CC distance (CCD), and complications. Continuous data were assessed using weighted standardized mean differences (SMDs) with 95% confidence intervals (CIs), and dichotomous data were evaluated with Mantel–Haenszel odds ratio (ORs) with 95% CIs.

Results

We analyzed one randomized control trial and four case–control studies comparing HP fixation with or without CC augmentation. A total of 474 patients with Rockwood type III or V ACJ dislocation were included. We found no differences in Constant–Murley score (SMD, − 0.58, 95% CI − 1.41 to 0.26; P = 0.18), American Shoulder and Elbow Surgeons score (SMD, 0.21, 95% CI − 0.10 to 0.52; P = 0.19), University of California at Los Angeles shoulder rating scale score (SMD, − 0.02, 95% CI − 1.27 to 1.23; P = 0.97), or VAS pain score (SMD, 0.36, 95% CI − 0.16 to 0.88; P = 0.17) between groups. The CC augmentation group had lower odds of osteolysis (OR, 0.27, 95% CI 0.10 to 0.74; P = 0.01) and a shorter CCD (SMD, − 0.29, 95% CI − 0.57 to − 0.01; P = 0.04).

Conclusion

HP fixation with CC augmentation is preferable for acute unstable ACJ dislocations. Although CC augmentation did not provide additional benefits related to functional outcomes or pain, it resulted in greater reduction maintenance after implant removal and a 73% lower risk of acromial osteolysis.

Trial registration

PROSPERO (CRD42021271118).

Clinical outcomes of bending versus non-bending of the plate hook in acromioclavicular joint dislocation

Background

We aimed to assess the effect of plate hook bending in treatment of acromioclavicular (AC) dislocation by analyzing clinical and radiological results according to the angle of the plate hook (APH).

Methods

This was a retrospective, observational, case-control study including 76 patients with acute AC joint dislocation that were divided into two groups according to treatment with bent or unbent plate hook. The visual analog scale (VAS), the American Shoulder and Elbow Surgeons (ASES) shoulder score, and range of motion (ROM) were evaluated as clinical outcomes. Comparative coracoclavicular distance (CCD) was measured to evaluate radiological outcomes.

Results

While the VAS and ASES of the bending group at 4 months after surgery were significantly higher (p=0.021 and p=0.019), the VAS and ASES of the bending group at other periods and ROM of the bending group showed no significant difference. The initial CCD decreased from 183.2%±25.4% to 114.3%±18.9% at the final follow-up in the bending group and decreased from 188.2%±34.4% to 119.1%±16.7% in the non-bending group, with no statistical difference (p=0.613). The changes between the initial and post-metal removal CCD were 60.2%±11.2% and 57.3%±10.4%, respectively, with no statistical difference (p=0.241). The non-bending group showed greater subacromial osteolysis (odds ratio, 3.87). Pearson’s coefficients for the correlation between APH and VAS at 4 months after surgery and for that between APH and ASES at 4 months after surgery were 0.74 and –0.63 (p=0.027 and p=0.032), respectively.

Conclusions

The APH was associated with improved postoperative pain and clinical outcomes before implant removal and with reduced complications; therefore, plate hook bending is more useful clinically during plate implantation.

Failure of Acromioclavicular Joint Reconstruction Eight Weeks After Hook Plate Removal: A Case Report

A female patient who underwent successful reconstruction of an acute high-grade acromioclavicular (AC) joint separation with hook plate presented with failure of the reduction eight weeks after removal of the hardware. Surgeons and patients should be aware of the risk of late failure of acromioclavicular reconstruction after removal of the hook plate.

Operative treatment of acute acromioclavicular joint dislocations graded Rockwood III-V: a retrospective and comparative study between three different surgical techniques

BACKGROUND

the optimal treatment of acute type III-V acromioclavicular (A-C) Rockwood dislocations is still a matter of discussion in orthopaedic surgery.

AIM OF THE WORK

retrospective and comparative evaluation of the clinical and radiographic results of three different surgical techniques for stabilization of A-C joint using tension band wiring, hook plate and TightRope.

METHODS

a consecutive series of patients, treated from January 2014 and November 2019, were divided into three groups according to the surgical method used. They were clinically and radiographically assessed and the results were compared with those present in the literature.

RESULTS

66 patients, with a mean age of 44.7 years, were enrolled with a mean follow-up of 37.7 months (range 6-58 months). All patients, regardless of the group, had satisfactory outcome. According to the DASH score, statistically significant difference favours the TightRope Group (TRG) fixation (p<0.005). The TRG showed the highest mean Constant score (96,1); there are no significative differences between the clinical scores of Hook Plate Group (HPG) and Tension Band Wiring Group (TBWG). However, these two methods showed numerous complications, especially metal-work mobilization and stiffness respectively.

CONCLUSIONS

good results can be overall achieved with primary fixation by the three different surgical methods under investigation. The TightRope system exhibited some advantages such as higher clinical scores, early recovery of range of  movements, longitudinal surgical incision with non-keloid scar, no need for a second surgery and lower rate of complications.

Biologic and synthetic ligament reconstructions achieve better functional scores compared to osteosynthesis in the treatment of acute acromioclavicular joint dislocation

PURPOSE

To systematically review the outcomes of surgical treatments of acute acromioclavicular joint dislocation.

METHODS

Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of acute acromioclavicular joint dislocations were included. Following data were extracted: authors and year, study design, level of evidence, number of patients, age, classification of acromioclavicular joint dislocation, time to surgery, surgical technique, follow-up, clinical and imaging outcomes, complications, and failures. Descriptive statistics was used, when a data pooling was not possible. Comparable outcomes were pooled to generate summary outcomes reported as frequency-weighted values. Quality appraisal was assessed through the MINORS checklist.

RESULTS

One hundred and thirty-three studies were included for a total of 4473 shoulders. Mean age of participants was 36.9 years. Mean follow-up was 42.06 months. Arthroscopy showed better ASES (p < 0.0001) and lower VAS pain score (p = 0.0249) compared to an open approach. Biologic and synthetic reconstructions demonstrated better results over osteosynthesis techniques. Biologic techniques showed overall better Constant (p = 0.0001) and DASH (p = 0.0215) scores, while synthetic reconstruction showed better UCLA score (p = 0.0001). Among suture buttons, triple button showed overall better results in Constant (p = 0.0001) and VAS (p = 0.0001) scores, while better results in DASH score (p = 0.0003) were achieved by 2 double button techniques. Overall, the level of evidence was low.

CONCLUSION

Biological and synthetic reconstructions achieved better functional scores compared to osteosynthesis. Among suture buttons, the triple button showed better functional performance.

LEVEL OF EVIDENCE

IV.

Rockwood Grade-III Acromioclavicular Joint Separation: A Cost-Effectiveness Analysis of Treatment Options

Background:

The treatment of Rockwood Grade-III acromioclavicular (AC) joint separation has been widely disputed since the introduction of the classification system. The present literature does not reach consensus on whether operative or nonoperative management is more advantageous, nor does it effectively distinguish between operative measures. We hypothesized that nonoperative treatment of Rockwood Grade-III AC joint separation would be more cost-effective when compared with surgical options.

Methods:

We created a decision-tree model outlining the treatment of Rockwood Grade-III separations using nonoperative management or hook-plate, suture-button, or allograft fixation. After nonoperative intervention, the possible outcomes predicted by the model were uneventful healing, delayed operative management, a second round of sling use and physical therapy, or no reduction and no action; and after operative intervention, the possible outcomes were uneventful healing, loss of reduction and revision, and depending on the implant, loss of reduction and no action, or removal of the implant. A systematic review was conducted, and probabilities of each model state were averaged. A cost-effectiveness analysis was conducted both through rollback analysis yielding net monetary benefit and through incremental cost-effectiveness ratios (ICERs). Thresholds of $50,000/quality-adjusted life-year (QALY) and $100,000/QALY were used for ICER analysis. Furthermore, a sensitivity analysis was utilized to determine whether differential probabilities could impact the model.

Results:

Forty-five papers were selected from a potential 768 papers identified through our literature review. Nonoperative treatment was used as our reference case and showed dominance over all 3 of the operative measures at both the $50,000 and $100,000 ICER thresholds. Nonoperative treatment also showed the greatest net monetary benefit. Nonoperative management yielded the lowest total cost ($6,060) and greatest utility (0.95 QALY). Sensitivity analysis showed that allograft fixation became the favored technique at a willingness-to-pay threshold of $50,000 if the rate of failure of nonoperative treatment rose to 14.6%. Similarly, at the $100,000 threshold, allograft became dominant if the probability of failure of nonoperative treatment rose to 22.8%.

Conclusions:

The cost-effectiveness of nonoperative treatment is fueled by its notably lower costs and overall high rates of success in Grade-III separations. It is important to note that, in our analysis, the societal cost (measured in lost productivity) of nonoperative treatment neared that of surgical treatment, but the cost from the health-care system perspective was minimal. Physicians should bear in mind the sensitivity of these conclusions and should consider cost-effectiveness analyses in their decision-making guidelines.

Level of Evidence:

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Editorial Commentary: Suture Button-Anchor Fixation Is Preferable to Hook Plate Fixation for Acute Acromioclavicular Joint Dislocations: Form and Function Need to Be United

Both hook plate fixation and suture button-anchor fixation have been reported to yield good results in the treatment of acute acromioclavicular joint reconstruction. In addition to a mandatory secondary procedure, hook plate fixation clearly has an increased prevalence of post-traumatic acromioclavicular arthritis in the short term that is likely to progress in the long term. Conversely, suture button-anchor fixation-a minimally invasive technique that creates less soft-tissue disruption, does not require hardware removal, and does not violate the acromioclavicular joint-is more likely to promote primary healing of the coracoclavicular ligaments, reduce the risk of late displacement, and minimize the development of post-traumatic acromioclavicular arthritis. As stated by the noted architect Frank Lloyd Wright, it is not only about form (i.e., alignment), it is about function as well.

Comparison of Hook Plate Fixation Versus Arthroscopic Coracoclavicular Fixation Using Multiple Soft Anchor Knots for the Treatment of Acute High-Grade Acromioclavicular Joint Dislocations

PURPOSE

To compare the clinical and radiologic outcomes of arthroscopically assisted coracoclavicular (CC) fixation using multiple soft anchor knots versus hook plate fixation in patients with acute high-grade Rockwood type III and V acromioclavicular (AC) joint dislocations.

METHODS

This retrospective study included 22 patients with acute Rockwood type III and V AC joint dislocations who underwent arthroscopic fixation or hook plate fixation surgery between February 2016 and March 2018. Patients were categorized into 2 groups: arthroscopically assisted CC fixation using multiple soft anchor knots group (AR, n = 12) and hook plate fixation group (HO, n = 10). We measured the CC distances (CCDs) and CCD ratio at 6 months, 1 year, and last follow-up postoperatively to compare the radiologic results between the groups. Clinical outcomes were assessed at 1 year postoperatively and at the last follow-up using the Visual Analog Scale, American Shoulder and Elbow Surgeons (ASES) scores, and Shoulder Pain and Disability Index (SPADI) scores, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Magnetic resonance imaging after hook plate removal was used to evaluate the healing ligaments and tendon-bone interface.

RESULTS

The patients in the AR group had better ASES, SPADI, and Quick DASH scores than the patients in the HO group at 1 year postoperatively and at last follow-up. The CCD and CCD ratio were significantly better in the AR group than in the HO group at the last follow-up period (P = .007/0.029). Magnetic resonance imaging findings showed grade I in 60% of patients in the AR group and grade III in 60% of patients in the HO group. AC joint arthritic change was observed in 40% of the HO group.

CONCLUSIONS

The CC fixation method using multiple soft anchor knots showed satisfactory results and had superior CC ligament healing ability and maintenance of CCD than hook fixation.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic comparative investigation.

Is coracoclavicular reconstruction necessary in hook plate fixation for acute unstable acromioclavicular dislocation?

Background

Acromioclavicular joint (ACJ) dislocation is a relatively common shoulder injury. For the treatment of cases of severe ACJ dislocation (Rockwood type III–V), hook plate fixation is an easy-to-master and minimally-invasive approach to surgical intervention. Over stress on the acromion following hook plate fixation often leads to acromial complications such as osteolysis and loss of reduction. We hypothesized that suspensory reconstruction alongside hook plate fixation might provide a superior stability and reduce complications as compared with hook plate fixation alone. The purpose of the study was to assess the clinical and radiographic outcomes of these two surgical modalities.

Methods

We retrospectively enrolled 49 patients with acute ACJ dislocation from May 2010 to December 2018. Among them, 19 patients received hook plate fixation only (HP group), and 19 underwent concomitant hook plate fixation and loop suspension fixation with two mersilene sutures (HM group). The demographic data of the patients were recorded and analyzed. All patients underwent a shoulder X-ray initially, immediately postoperatively, and at 1, 3, 6 and 12 months to measure the relative coracoclavicular distance (rCCD). Clinical assessment of shoulder function outcome was conducted using the Constant Murley Score (CMS); the University of California at Los Angeles (UCLA) Shoulder Score was also measured at the latest follow-up.

Results

There were no significant differences in the demographic data between the two groups. With regards to the CMS and the UCLA score, the HM group and HP group both had excellent outcomes, and no significant differences in scores were observed between groups (CMS: 93.90 ± 6.16 versus 94.47 ± 7.26, p = 0.47; UCLA score: 32.84 ± 2.91 versus 34.32 ± 1.16, p = 0.07). However, the HM group demonstrated substantial superiority in terms of maintenance of the rCCD over the HP group (91.47 ± 27.47 versus 100.75 ± 48.70, p = 0.015). In addition, there was less subacromial osteolysis in the HM group than the HP group (52.6% versus 15.8%, p = 0.038).

Conclusion

Both fixations yielded excellent functional outcomes. However, concomitant hook plate fixation with loop suspensory reconstruction demonstrated the fewer acromion complications and statistical differences in reduction maintenance with less clinical significance.

Hook plate with or without coracoclavicular ligament augmentation in the treatment of acute acromioclavicular separation

Background

Acromioclavicular (AC) separation can be treated with the use of a hook plate. Some studies have reported that coracoclavicular (CC) ligament augmentation is necessary to reduce the complications of hook plate fixation, whereas others recommend hook plate fixation alone without augmentation. The aim of this study was to compare the results and complications between these two groups.

Methods

This was an observational case-control study. Patients with acute (less than 2 weeks) Rockwood type V AC separation were treated with a hook plate at our hospital. A total of 105 cases received hook plate fixation with CC ligament augmentation (group I), and 112 cases received hook plate fixation without augmentation (group II). Constant-Murley scores were used to evaluate the function before and after implant removal, and radiographs were taken to evaluate the complications. The results and complications were compared between groups.

Results

Before removal, the Constant-Murley score was significantly higher in group I (mean, 50.1) than in group II (mean, 42.6) (p = 0.004); however, there was no significant difference between groups at 3 and 6 months after removal. The incidence of significant acromion osteolysis was higher in group II (65/112) than in group I (25/105). Before removal, the patients with significant acromion osteolysis had worse Constant-Murley scores than those of the patients without osteolysis in both groups. The incidence of peri-implant fracture of the hook plate was higher in group II (8/112) than in group I (1/105).

Conclusion

The patients without CC ligament augmentation had worse functional results before hook plate removal, a higher incidence of radiographic acromion osteolysis, and a higher incidence of peri-implant fractures than those patients with CC ligament augmentation. Therefore, CC ligament augmentation is highly recommended to improve short-term outcomes and decrease complications for Rockwood type V AC separation treated by hook plate.

Evaluation of the Clavicle Hook Plate for Treatment of Acromioclavicular Joint Dislocation: A Cadaveric Study

OBJECTIVES

To describe surgical technique for proper placement of the clavicle hook plate, determine whether there is subacromial impingement caused by hook plate fixation, and evaluate the mechanical strength of the clavicle hook plate construct.

METHODS

Eight fresh-frozen cadaveric shoulders with a mean age of 48 years (range, 37-69) were used. Open reduction and internal fixation of simulated Rockwood type V AC joint dislocation was performed with the clavicle hook plate. Three-dimensional computed tomography studies and arthroscopic evaluation were performed with the glenohumeral joint in different orientations to assess the position of the hook plate relative to relevant joint structures. The clavicle was then superiorly loaded to mechanical failure.

RESULTS

Computed tomography evaluations showed no contact between the humerus and the hook plate. Distance between the greater tuberosity and hook plate ranged from 14 to 31 mm with maximal shoulder forward flexion and 8.1-25.4 mm with maximal shoulder abduction. Arthroscopic evaluation of the subacromial space demonstrated that with maximal abduction/forward flexion, there was abutment of the rotator cuff with the hook plate in 6 of 8 specimens. In mechanical testing, mean failure load was determined to be 1011 N (range, 380-1563 N). Failure mechanisms included acromion fracture (4), slippage of the hook under acromion (3), and distal clavicle fracture (1).

CONCLUSIONS

This study demonstrates that the clavicle hook plate reduces AC joint dislocation or distal clavicle fractures anatomically, has supra-physiologic mechanical strength, does not cause bony impingement, and exhibits rotator cuff impingement only with maximal abduction/forward flexion of the shoulder.

Comparison of clavicular hook plate with and without coracoclavicular suture fixation for acute acromioclavicular joint dislocation

Objective

The aim of this study was to compare the clinical and radiographic outcomes of clavicular hook plate fixation with and without coracoclavicular (CC) tape augmentation for the treatment of acute unstable AC dislocation.

Methods

We treated 47 patients (31 men and 16 women; mean age: 47 years (range, 21–81)) with unstable acute AC dislocations (Rockwood III–V) and divided them into two groups according to the treatment modality, with hook plate fixation (hook plate group) or hook plate plus CC tape augmentation (combined group). We assessed radiologic findings, such as subacromial osteolysis and AC osteoarthritis. We also evaluated the clinical outcomes using a visual analogue scale (VAS) for pain, as well as the University of California at Los Angeles (UCLA) Shoulder Rating Scale and the American Shoulder and Elbow Surgeons (ASES) Shoulder Score.

Results

We found that the combined group had less subacromial osteolysis upon radiography, although the CC distance was similar in both groups (119 ± 29.7% of contralateral side CC distance in hook plate group versus 119 ± 34.8% in the combined group, p = 0.77). Compared with the hook plate group, the combined group had a lower VAS score (4.5 ± 2.3 in hook plate group versus 2.3 ± 1.4 in the combined group, p < 0.001), better UCLA scores (19.9 ± 4.9 in hook plate group versus 27.2 ± 4.0 in the combined group, p < 0.001) as well as better ASES scores (51.9 ± 17.8 in hook plate group versus 73.8 ± 13.1 in the combined group, p < 0.001) at 3 and 6 months after surgery.

Conclusion

Hook plate fixation plus CC tape augmentation may prevent subacromial osteolysis and yield better short-term functional outcomes.

Level of Evidence

Level III, Therapeutic Study.

Fifteen-degree clavicular hook plate achieves better clinical outcomes in the treatment of acromioclavicular joint dislocation

OBJECTIVE

Clavicular hook plate application is one of the most commonly used treatment methods for acromioclavicular (AC) joint dislocation, although it may cause multiple postoperative complications. We modified the regularly used 0° hook plate to 15° and compared the clinical outcomes of these two hook plates for treatment of AC joint dislocation.

METHODS

Forty-three patients with acute AC joint dislocation were randomly enrolled (0° hook plate, 20 patients; 15° hook plate, 23 patients). The American Shoulder and Elbow Surgeons (ASES) and visual analog scale for pain (VASP) scores were evaluated preoperatively and at 3 days and 1, 2, 3, and 6 months postoperatively and compared between the two groups.

RESULTS

Compared with the preoperative scores, the 6-month postoperative ASES score gradually increased but the VASP score decreased in both groups. Furthermore, the ASES and VASP scores were significantly different between the two groups at every postoperative time point.

CONCLUSION

The 15° hook plate is superior to the 0° hook plate in reducing shoulder pain and improving postoperative recovery in the treatment of AC joint dislocation.

LEVEL OF EVIDENCE

Level III; Treatment study (retrospective comparative study).

A novel hybrid fixation (coracoclavicular screw supplemented with K-wire) for the treatment of acute acromioclavicular joint dislocation: A prospective study

OBJECTIVE

The aim of this study was to compare the radiological and clinical outcomes of clavicular hook plate fixation and the coracoclavicular lag screw supplemented with K-wire fixation in the treatment of acute acromioclavicular joint dislocation.

METHODS

Between January 2012 to December 2015, 81 patients with acute acromioclavicular joint dislocation were included in this prospective study. 43 patients were treated with clavicular hook plate fixation (Group A) and 38 patients were treated with coracoclavicular lag screw supplemented with K-wire fixation (Group B). Incision length, operation duration, blood loss volume, intraoperative fluoroscopy times and length of hospitalization were recorded. Radiographic outcomes, functional outcomes and complications were also recorded.

RESULTS

Both two groups could achieve good radiographic and functional outcomes after operation. Group B exhibited significantly shorter operation duration, shorter length of incision, less blood loss volume and shorter length of hospitalization than Group A (P < 0.001). In addition, significant difference could be found between the two groups regarding the VAS scores three month postoperatively and the final follow-up (P < 0.001). However, there was no significant difference in radiographic and functional outcomes between the two groups (P > 0.05).

CONCLUSION

The two groups can both achieve satisfactory radiological and functional outcomes in treating acute AC joint dislocation. However, CC screw fixation supplemented with K-wire exerts some advantages regarding the incision length, operation duration, blood loss volume, length of hospitalization. Furthermore, it can better relieve the pain caused by dislocation. Therefore, the novel hybrid fixation (CC screw fixation supplemented with K-wire) provides an alternative treatment for acute AC joint dislocation.

Acute Fixation of Type IV and V Acromioclavicular Separations: An Internal Splint Technique

Background:

There is no standard method for the surgical treatment of acromioclavicular (AC) joint separations. Current techniques have associated complications, including need for device removal, coracoid fracture, and inadequate reduction.

Purpose:

To evaluate the clinical outcomes of an internal splint technique without graft augmentation or rigid fixation to treat acute Rockwood type IV and V AC joint injuries.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective analysis was performed of 26 patients who underwent a novel internal splint fixation technique between 2011 and 2016. Patients had type IV (n = 2) and type V (n = 24) acute AC separations. The mean time to surgery was 13.7 days (range, 1-28 days). The surgical technique included an open approach with coracoclavicular suture and tape fixation and AC suture fixation. Range of motion, strength, and radiographs were evaluated after surgery. Patient follow-up included the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire at a mean 3.3 years postoperatively (range, 6 months–8.6 years). DASH questionnaires were obtained for all patients via email. Patients were also surveyed on cosmetic appearance and willingness to undergo the operation again.

Results:

All patients regained full strength and range of motion following surgery. All postoperative radiographs demonstrated well-maintained reduction of the AC joint. The mean DASH score was 3.4 at final follow-up, and 23 of 26 respondents were satisfied with their postoperative shoulder appearance. There were no reoperations, and all patients stated that they would have the operation again given the same circumstances.

Conclusion:

The results of this study demonstrate a reliable new technique for acute fixation of type IV or V AC joint injuries via an internal splint construct. This technique enables reduction in the coronal and sagittal planes without the need for graft augmentation or a rigid implant, allowing healing of the coracoclavicular and AC ligaments.

Arthroscopic fixation of acute acromioclavicular joint disruption with TightRope™: Outcome and complications after minimum 2 (2-5) years follow-up

PURPOSE

To evaluate the midterm results of arthroscopic reconstruction of acute acromioclavicular (AC) joint disruption using TightRope™ system.

METHODS AND MATERIAL

We retrospectively assess the results of 24 patients of acute AC joint dislocation who were operated using TightRope system. Constant and University of California, Los Angeles (UCLA) scores and coracoclavicular distance were calculated pre- and postoperatively. Data was entered into MS excel and analyzed using the SPSS version 17.

RESULTS

The mean follow-up was 39.45 months. Constant and UCLA scores were significantly increased postoperatively. Six patients had partial loss of reduction within 3-6 months and two patients had a failure of construct. Constant score was significantly lower in these patients.

CONCLUSION

TightRope reconstruction of the AC joint is a reproducible and safe alternative to many other techniques of AC joint reconstruction. Early subluxation remains a concern and may reflect the need for technique modification.

Modified Internal Fixation Technique for Acromio-Clavicular (AC) joint dislocation: The "Hidden Knot Technique"

Acromioclavicular (AC) joint injuries are common and often seen in contact athletes, resulting from a fall on the shoulder tip with adducted arm. This joint is stabilized by both static and dynamic structures including the coracoclavicular (CC) ligament. Most reconstruction techniques focus on CC ligament augmentation as the primary stabilizer of the AC joint. The best surgical technique for some AC joint dislocations is still controversial. In this study, we explained a modification of the CC ligament reconstruction technique described by Wellmann. The method is based on minimally invasive CC ligament augmentation with a flip button/polydioxanone (PDS) repair, typically used for extracortical ACL graft fixation. Patients commonly complain that heavy sutures under the skin in subcutaneous tissue irritate the skin and sometimes require reoperation for suture removal. We present an augmentation technique that resolves this issue by changing the suture knot location to the sub-clavicular position. Level of evidence: II.

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.

Surgical versus conservative management of Type III acromioclavicular dislocation: a systematic review

INTRODUCTION

The management of Type III acromioclavicular (AC) dislocations is still controversial. We wished to compare the rate of recurrence and outcome scores of operative versus non-operative treatment of patients with Type III AC dislocations.

SOURCE OF DATA

A systematic review of the literature was performed by applying the PRISMA guidelines according to the PRISMA checklist and algorithm. A search in Medline, PubMed, Cochrane and CINAHL was performed using combinations of the following keywords: 'dislocation', 'Rockwood', 'type three', 'treatment', 'acromioclavicular' and 'joint'.

AREAS OF AGREEMENT

Fourteen studies were included, evaluating 646 shoulders. The rate of recurrence in the surgical group was 14%. No statistical significant differences were found between conservative and surgical approaches in terms of postoperative osteoarthritis and persistence of pain, although persistence of pain seemed to occur less frequently in patients undergoing a surgical treatment.

AREAS OF CONTROVERSY

Persistence of pain seemed to occur less frequently in patients undergoing surgery.

GROWING POINTS

Persistence of pain seems to occur less frequently in patients treated surgically for a Type III AC dislocation.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is insufficient evidence to establish the effects of surgical versus conservative treatment on functional outcome of patients with AC dislocation. High-quality randomized controlled clinical trials are needed to establish whether there is a difference in functional outcome.

Post-operative outcomes and complications of suspensory loop fixation device versus hook plate in acute unstable acromioclavicular joint dislocation: a systematic review and meta-analysis

BACKGROUND

Treatment of acute (≤3 weeks) acromioclavicular joint dislocation type III-VI is still controversial. Currently, the two modern techniques that are widely used are hook plate (HP) fixation and coracoclavicular ligament fixation using a suspensory loop device that consists of either a tightrope (single or double), endo-button (single or double), or synthetic ligament and absorbable polydioxansulfate sling.

MATERIALS AND METHODS

This systematic review was conducted according to the PRISMA guidelines. Relevant studies that reported Constant-Murley score (CMS), Pain Visual Analog score (VAS) and postoperative complications of either technique were identified from Medline and Scopus from inception to 5 October 2015.

RESULTS

Sixteen studies were included for the analysis of HP fixation, and 25 studies were included for analysis of loop suspensory fixation (LSF). Pooling of mean CMS and VAS scores gave 90.35 (95% CI 87.16, 93.54), 1.51 (95% CI 0.73, 2) in the HP group, and 92.48 (95% CI 90.91, 94.05), 0.32 (95% CI 0, 0.64) in the suspensory loop devices group, respectively. The pooled unstandardized mean differences (UMD) scores of CMS and VAS in LSF were 2.13 (95% CI -1.43, 5.69) and -1.19 (95% CI -2.03, -0.35) when compared to hook plating. The pooled prevalence of LSF and hook plating were 0.08 (95% CI 0.06, 0.10) and 0.05 (95% CI 0.02, 0.08) scores. The chance of having complications in the LSF group was 1.69 (95% CI 1.07, 2.60), which was statistically significantly higher than in the HP group.

CONCLUSION

LSF have higher shoulder function scores (CMS) and lower postoperative pain when compared to HP fixation; however, there are higher complication rates with LSF when compared to hook plating.

LEVEL OF EVIDENCE

IV.

Acute high-grade acromioclavicular dislocations treated with triple button device (MINAR): Preliminary results

OBJECTIVE

Describe the clinical and radiological results of triple button device in the treatment of high-grade AC dislocations (Rockwood, type V) and assess whether improves vertical and horizontal stability compared to the techniques previously described.

MATERIAL AND METHODS

This retrospective study included 39 patients with type V acromioclavicular dislocations treated with Twin Tail TightRope™ system (triple button device). Of the 39 patients, 33 (26 men and 7 women) were able to participate in clinical and radiographic follow up. At the time of surgery, the mean age was 25years±7(range, 17-49). All patients underwent bilateral-weighted Zanca (CC distance) and Alexander view (AC distance) as well as the Constant Score (CS) and Acromioclavicular Joint Instability Scoring System (ACJI). Radiological and clinical outcome was assessed during routine follow-up examinations preoperatively, postoperatively, 1, 3, 6 months and every year after the surgery. The presence of calcification, degenerative changes, mobilization of implants and bone resorption were also assessed.

RESULTS

After a mean follow up of 25±4months (range 14-38), the results of the Constant (CS) were 94.1±5,5 (range 76-100) and test ACJI 87.3±9,8 (range 65-100), showing no significant differences with the uninjured shoulder (CS 95.8±2.5, range 83-100; ACJI 94.1±3.7, range 80-100). At final review, we observed that preoperative coracoclavicular distance (Zanca View) improved from 21,75±1.97mm to 8,73mm±0.75 and the acromioclavicular distance (Alexander View) from 12,65mm±1.99 to 0,35±0.3mm. Compared with healthy shoulder, these differences were not significant. There was no loss of reduction with this system in the vertical plane. 4 patients (12.12%) revealed signs of posterior instability with worse clinical test results. The presence of degenerative joint changes (6,06%), calcifications (27,2%) or mobilization of the implant (18,18%) was not associated with worse clinical outcomes.

CONCLUSION

Twin Tail device using minimally invasive technique improves stability in the vertical and, specially in the horizontal plane relative to the previously described techniques without increasing number of complications.