Operative treatment of chronic acromioclavicular dislocation

Anatomic reconstruction of acromioclavicular joint dislocations using allograft and synthetic ligament

Background

Acromioclavicular (AC) separations are commonly seen shoulder injuries. Numerous surgical reconstruction techniques have been described. In this study, we present a series of patients who underwent an anatomic reconstruction using a synthetic ligament and allograft construct.

Methods

We performed a retrospective review of patients with type IV or V AC separations who underwent primary or revision AC reconstruction with a luggage-tag synthetic ligament and a semitendinosus allograft placed through the anatomic insertion sites of the coracoclavicular ligaments. Patient-reported outcomes, as well as complication rates, were recorded at a minimum 2-year follow-up.

Results

Ten patients with a mean age of 44.2 ± 14.9 years were included in the study. The mean Disabilities of the Arm, Shoulder and Hand score was 15.5 ± 15.4; mean Single Assessment Numeric Evaluation score, 81.8 ± 12.1; mean Simple Shoulder Test score, 11.4 ± 1.1; mean American Shoulder and Elbow Surgeons score, 84.6 ± 15.7; mean Constant score, 82.5 ± 11.6; and mean visual analog scale score, 2 ± 2.6.

Conclusion

The technique using a luggage-tag synthetic ligament along with an anatomic allograft coracoclavicular ligament reconstruction is a safe, effective alternative to other techniques described in the literature.

Acromioclavicular joint injuries: Imaging and management

Acromioclavicular joint injuries are commonly encountered in the setting of shoulder trauma. Knowledge of the anatomy and biomechanics of the joint, grading of joint injuries, and understanding the capabilities and limitations of different radiological modalities will help in selecting the best management option and outcomes for affected patients.

Modified Weaver-Dunn procedure versus the use of a synthetic ligament for acromioclavicular joint reconstruction

PURPOSE. To compare the subjective outcome of acromioclavicular joint (ACJ) reconstruction using the modified Weaver-Dunn procedure versus the Surgilig synthetic ligament. METHODS. 55 patients aged 19 to 72 (mean, 42) years underwent ACJ reconstruction of Rockwood grade 3 (n=38), grade 4 (n=8), and grade 5 (n=9) using the modified Weaver-Dunn procedure (n=31) or the Surgilig synthetic ligament (n=24), based on the surgeon's preference. The mean period from injury to surgical treatment was 39 months. Subjective outcomes were assessed before and after surgery using the Oxford Shoulder score and Nottingham Clavicle score. The time required to return to work and sports was also recorded. RESULTS. After a mean follow-up period of 40 months, the mean Oxford Shoulder scores improved from 28 to 42 in the Weaver-Dunn group (p=0.009), and from 26 to 45 in the Surgilig group (p=0.007), whereas the respective mean Nottingham Clavicle scores improved from 53 to 81 (p=0.047) and from 51 to 93 (p=0.023). The Surgilig group achieved significantly better postoperative Oxford Shoulder score (p=0.008) and Nottingham Clavicle score (p=0.007), and could also return to work (14 vs. 6 weeks, p<0.001) and sports (25 vs. 12 weeks, p<0.001) sooner than the Weaver-Dunn group. Three patients in the Weaver- Dunn group and one patient in the Surgilig group had persistent pain and/or functional deficit with evidence of ACJ dislocation. CONCLUSION. Chronic ACJ reconstruction using the Surgilig synthetic ligament achieved better Oxford Shoulder score and Nottingham Clavicle score and earlier return to work and sports, compared with the modified Weaver-Dunn procedure.

Clinical results of coracoacromial ligament transfer in acromioclavicular dislocations: A review of published literature

Acromioclavicular joint dislocations are common injuries, which typically occur with trauma in young men. Treatment recommendations for these injuries are highly variable and controversial. There are greater than 100 surgical techniques described for operative treatment of this injury. One of the most widely recommended methods of surgical reconstruction for acromioclavicular joint dislocations is to utilize the coracoacromial ligament for stabilization of the distal clavicle. Several modifications of this procedure have been described which have involved adjunct coracoclavicular fixation or fixation across acromioclavicular joint. Although the literature is replete with descriptive papers, there is paucity of studies evaluating the surgical outcome of this procedure. We systematically reviewed the English language published literature in peer reviewed journals (Medline, EMBASE, SCOPUS) and assigned a level of evidence for available studies. We critically reviewed each paper for the flaws and biases and then evaluated the comparable clinical outcomes for various procedures and their modifications. The published literature consists entirely of case series (Level IV evidence) with variability in surgical technique and outcome measures. On review there is low level evidence to support the use of coracoacromial ligament for acromioclavicular dislocation but it has been associated with high rate of deformity recurrence. Adjunct fixation does not improve clinical results when compared to isolated coracoacromial ligament transfer. This is in part because of the high incidence of fixation related complications. Similar results are reported with coracoacromial ligament reconstruction for acute and chronic cases. The development of secondary acromioclavicular joint symptoms with distal clavicle retention is poorly reported with the incidence rate varying from 12% to 32%. Despite this, the retention or excision of distal clavicle did not affect overall clinical results except in the patients with pre existing acromioclavicular joint osteoarthritis who have inferior results with retention of distal end of clavicle. Further well designed clinical trials with validated outcome measures are required to fully evaluate the clinical results of this procedure.

Surgical outcome following arthroscopic fixation of acromioclavicular joint disruption with the tightrope device

The objective of this study was to evaluate the preliminary radiographic and clinical results of grade IV and V acromioclavicular joint disruption repair using the arthroscopic Arthrex acromioclavicular TightRope (Naples, Florida) fixation technique. Numerous procedures have been described for surgical management of acromioclavicular joint disruption. The TightRope device involves an arthroscopic technique that allows nonrigid anatomic fixation of the acromioclavicular joint. A cohort of 10 men and 2 women with a mean age of 43 years (range, 25-61 years) underwent the acromioclavicular joint TightRope procedure between April 2007 and October 2009. Eleven patients had either Rockwood grade IV or V disruptions and 1 sustained a distal third clavicle fracture with acromioclavicular joint disruption. Data was collected from a chart review. Patients were evaluated clinically, radiographically, by the simple shoulder test, and by overall satisfaction. There were 2 failures of reduction and 1 loss of reduction at final radiographic follow-up. The rate of fixation failure was 16.6%. All patients had >110° of total elevation. The majority of patients obtained satisfactory functional results according to the Simple Shoulder Test averaging 11 of 12 questions answered positively (range, 7-12; standard deviation, 1.50) and 11 of 12 patients were satisfied with the procedure. At final phone interview at approximately 2 years postoperatively, 6 patients were lost to follow-up. The remaining patients were all satisfied with the procedure and no patients reported subjective loss of reduction or deterioration of function. Simple Shoulder Test average was maintained with 11 of 12 positively answered questions (range, 7-12; standard deviation, 2.0) This case series revealed a high rate of fixation failure with the TightRope system. Still, most patients were satisfied with the procedure and achieved high functional shoulder results.

Luggage tag technique of anatomic fixation of displaced acromioclavicular joint separations

Acromioclavicular joint dislocations are common injuries in active individuals. Most of these injuries may be treated nonoperatively. However, many techniques have been described when surgical management is warranted. A recent biomechanical study favors anatomic reconstruction of the conoid and trapezoid ligaments and the acromioclavicular joint capsule, as opposed to the traditional technique of excision of the lateral end of clavicle and transfer of the coracoacromial ligament to the intramedullary canal of the distal clavicle. We present a modification of the anatomic fixation technique using a luggage tag method, which places a graft under the base of the coracoid. This procedure has been associated with few redisplacements of the distal clavicle, reliable pain relief, and minimal postoperative morbidity. We found the luggage tag technique provides anatomic fixation of the distal clavicle and restoration of coronal and sagittal plane stability to the injured acromioclavicular joint. This procedure should reduce the possibility of coracoid fracture and decreases the risk of hardware complications associated with reconstruction techniques that violate the base of the coracoid process.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases: a prospective comparative study

BACKGROUND

Biomechanical studies comparing various surgical techniques for acromioclavicular joint reconstruction have reported that semitendinosus tendon graft for coracoclavicular ligament reconstruction provides a substantial improvement in initial stability and a load-to-failure equivalent to the intact coracoclavicular ligaments. Although it represents a biomechanical improvement compared with coracoacromial ligament transfer, there is still a lack of prospective comparative studies confirming the clinical relevance of these biomechanical findings.

HYPOTHESIS

Semitendinosus tendon graft for coracoclavicular ligament reconstruction is associated with superior clinical results compared with a modified Weaver-Dunn procedure in chronic complete acromioclavicular joint dislocation.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Twenty-four patients (mean age, 42 years) with painful, chronic Rockwood type III through V acromioclavicular joint dislocations were subjected to surgical reconstruction. In 12 patients, a modified Weaver-Dunn procedure was performed; in the other 12 patients, autogenous semitendinosus tendon graft was used. Clinical evaluation was performed using the American Shoulder and Elbow Surgeons shoulder score and the Constant score after a mean follow-up time of 37 months. Preoperative and postoperative radiographs were compared.

RESULTS

The mean American Shoulder and Elbow Surgeons shoulder score improved from 74 +/- 7 points preoperatively to 86 +/- 8 points postoperatively in the Weaver-Dunn group, and from 74 +/- 4 points to 96 +/- 5 points in the semitendinosus tendon group (P < .001 for both techniques). The mean Constant score improved from 70 +/- 8 points to 81 +/- 8 points in the Weaver-Dunn group, and from 71 +/- 5 points to 93 +/- 7 points in the semitendinosus tendon group (P < .001). The results in the semitendinosus tendon group were significantly better than in the Weaver-Dunn group (P < .001). The radiologic measurements showed a mean coracoclavicular distance of 12.3 +/- 4 mm in the Weaver-Dunn group increasing to 14.9 +/- 6 mm under stress loading, compared with 11.4 +/- 3 mm increasing to 11.8 +/- 3 mm under stress in the semitendinosus tendon group. The difference during stress loading was statistically significant (P = .027). In the semitendinosus tendon group, horizontal displacement of the lateral clavicle end could be reduced in all cases with type IV dislocation.

CONCLUSION

Semitendinosus tendon graft for coracoclavicular ligament reconstruction resulted in significantly superior clinical and radiologic outcomes compared to the modified Weaver-Dunn procedure.

Triple Endobuttton Technique in Acromioclavicular Joint Reduction and Reconstruction

Introduction: Acromioclavicular joint (ACJ) dislocation is a common injury often affecting young athletes. Cyclist, ice hockey players, weight lifters, rugby players and martial exponents are the most common athletes sustaining these injuries. Majority of these athletes sustain high-grade injuries requiring surgical management to allow them to return to their sports. Methods: The author describes a new technique to reduce and maintain reduction of the coraco-clavicular interval, using 3 low profile metallic buttons technique. The fixation device comprises 3 endobuttons (Acufex, Smith & Nephew, Andover, MA) and 2 #5 FibrewireTM suture. Two endobuttons will sit on the clavicle and the third will be flipped at the undersurface of the coracoid. The proposed advantages include a non-rigid fixation of the AC joint which maintains reduction yet allowing for normal movement at the joint. The “snow shoe” hold on cortical bone means that the implant should withstand cyclic loading without cutting out from the bone. The theoretical strength of the fixation is also superior than the original strength of the coraco-clavicular ligaments. The relatively low profile means that there is no need for removal of implant. Results: The author has utilised this fixation technique on 5 patients. All the patients had strong intraoperative fixation. Immediate, 2 weeks and 6 months postoperative radiographs demonstrated excellent reduction of the coracoclavicular interval and the AC joint. Conclusion: The short-term follow-up with this technique proves to be a safe and effective way for providing fixation for the ACJ. Key words: Acromio-clavicular ligament, Coraco-clavicular ligament, Coraco-clavicular interval, Endobutton

Surgical treatment of complete acromioclavicular dislocations

Forty-four patients, ranging in age from 17 to 57 years (average, 32), were evaluated an average of 4 years (range, 2 to 9) after surgical reconstruction for Allman-Tossy Grade III acromioclavicular dislocations. Twenty-seven patients underwent repair for acute injuries (< 3 weeks after injury) and 17 patients underwent reconstructions for chronic injuries (> 3 weeks). Coracoclavicular fixation with heavy nonabsorbable sutures was used to correct superior displacement in all cases. In addition, transfer of the coracoacromial ligament to the distal clavicle was performed in 15 of the 27 early repairs and 17 of the 17 late reconstructions. Overall, 26 of 27 (96%) early repairs and 13 of 17 (77%) late reconstructions achieved satisfactory results. There was a trend for better results and return to sports or heavy labor with early repairs; however, this was not statistically significant (P = 0.065). When the results of early repairs were compared with those of late reconstructions performed more than 3 months after injury, the results of the shoulders undergoing early repair were significantly better (P < 0.01). Overall, 39 of 44 (89%) patients achieved a satisfactory result. Surgical reconstruction for acromioclavicular dislocation provides reliable results including use of the arm for sports or repetitive work.