Better Radiographic Reduction and Lower Complication Rates With Combined Coracoclavicular and Acromioclavicular Ligament Reconstruction Than With Isolated Coracoclavicular Reconstruction

Acromioclavicular Joint Reconstruction With Acromioclavicular Ligament Augmentation Using a Knotless, All-Suture Anchor Construct

Many techniques and combinations of procedures exist for reconstruction of an injured acromioclavicular (AC) joint. Recently, there has been a focus on controlling anterior and posterior translation of the AC joint after the reduction of superior translation and coracoclavicular (CC) ligament stabilization. Diagnosis and treatment of anterior and posterior instability of the AC joint is critical, yet when AC/CC ligament reconstruction fails, this is often the result of recurrent superior migration of the clavicle relative to the acromion. We present a technique using knotless, all-suture anchor technology intended for higher-grade, operative AC joint injuries in "high-risk" patients, i.e., those returning to a collision sport such as football, rugby, hockey, or wrestling. Consideration also could be given to those performing a high-demand occupation, such as overhead work or manual labor. In addition, this technique could be employed in patients at risk for delayed or nonhealing, such as those with diabetes or who are smokers, those at risk of noncompliance, and revision cases. The all-suture anchor, knotless "suture staple" technique can be implemented easily to provide backup fixation of the AC joint directly as an augmentation to CC reconstruction, preferably arthroscopic-assisted reduction, and fixation with a cortical button and, when indicated, concomitant allograft reconstruction.

Complications after operative treatment of high-grade acromioclavicular injuries

BACKGROUND

Treatment of Rockwood type III-V acromioclavicular (AC) joint injuries remains controversial. Numerous reconstruction techniques have been proposed. The purpose of this study was to describe the complication profile in a large cohort of patients who underwent surgical management of AC joint separations using a variety of reconstruction strategies.

METHODS

All patients who underwent surgery for AC joint injuries from 2013 to 2019 at a single institution were identified. Chart review was performed to capture patient demographics, radiographic measurements, operative techniques, postoperative complications, and revision surgery. Structural failure was defined as a radiographic loss of reduction of greater than 50% when comparing immediate and final postoperative imaging. Logistic regression analysis was performed to identify risk factors for complications and revision surgery.

RESULTS

Of the 279 patients included in the study, 66 (24%) had type III separations, 20 (7%) type IV, and 193 (69%) type V. Fifty-three percent underwent surgery acutely (<6 weeks of injury), and 40% were chronic (>3 months). A total of 252 of the 279 surgeries (90%) were performed open and 27 (10%) were arthroscopically assisted. Allograft was used in 164 of 279 (59%) cases. Specific operative techniques (with or without allograft) included hook plating (1%), modified Weaver Dunn (16%), cortical button fixation (18%), and suture fixation (65%). At mean 28-week follow-up, 108 complications were identified in 97 patients (35%). Complications were identified at mean 20 ± 21 weeks. Sixty-nine structural failures (25%) were identified. Persistent AC joint pain requiring injection, clavicle fracture, adhesive capsulitis, and hardware complications were the other most common complications. Twenty-one patients (8%) underwent unplanned revision surgery at mean 38 ± 28 weeks after the index procedure, with the most common indication for structural failure, hardware complications, or fracture of the clavicle or coracoid. Patients who had surgery after 6 weeks from injury had a significantly greater risk of having a complication (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.34-7.77, P = .009) and a significantly greater risk of having structural failure (OR 2.65, 95% CI 1.38-5.28, P = .004). Patients who had an arthroscopic technique had a greater risk of structural failure (P = .002). Complications, structural failure, and revision surgery were not significantly correlated with use of allograft or specific operative techniques.

CONCLUSION

Surgical management of AC joint injuries is associated with a relatively high complication profile. Loss of reduction in the postoperative period is common. However, the revision surgery rate is low. These findings are important for patient preoperative counseling.

Treatment options for acute Rockwood type III-V acromioclavicular dislocations: a network meta-analysis of randomized controlled trials

BACKGROUND

Acute Rockwood type III-V acromioclavicular (AC) dislocations have been treated with numerous surgical techniques over the years. The purpose of this study was to perform a network meta-analysis (NMA) of randomized controlled trials to quantitatively define the optimal treatment for AC dislocations requiring operative treatment.

METHODS

A literature search of 3 databases was performed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Randomized controlled trials comparing 1 of 10 treatments for acute Rockwood type III-V AC dislocations-nonoperative treatment, Kirschner wire fixation (KW), coracoclavicular screw fixation (Scr), hook plate (HP), open coracoclavicular cortical button (CBO), arthroscopic coracoclavicular cortical button (CBA), ≥2 coracoclavicular cortical buttons (CB2), isolated graft reconstruction (GR), cortical button with graft augmentation (CB-GR), and coracoclavicular and acromioclavicular fixation (AC)-were included. Clinical outcomes were compared using a frequentist approach to NMA, with statistical analysis performed using the R program. Treatment options were ranked using the P-score, which estimates the likelihood that the investigated treatment is the ideal method for an optimal result in each outcome measure on a scale from 0 to 1.

RESULTS

Of 5362 reviewed studies, 26 met the inclusion criteria, with a total of 1581 patients included in the NMA. AC, CB-GR, GR, CB2, CBA, and CBO demonstrated superiority over HP, Scr, KW, and nonoperative treatment at final follow-up for the Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score, with AC and CB-GR showing the highest P-scores for the Constant-Murley score (0.957 and 0.781, respectively) and GR and CBO showing the highest P-scores for the Disabilities of the Arm, Shoulder and Hand score (0.896 and 0.750, respectively). GR had the highest P-score for the visual analog scale score (0.986). HP, CB2, CB-GR, AC, CBA, and CBO demonstrated superiority in the coracoclavicular distance (CCD) and recurrence at final follow-up, with HP and CB2 having the highest P-scores for the CCD (0.798 and 0.757, respectively) and with GR and CB-GR having the highest P-scores for recurrence (0.880 and 0.855, respectively). KW and Scr showed the shortest operative times (P-scores of 0.917 and 0.810, respectively), whereas GR and CBA showed the longest operative times (P-scores of 0.120 and 0.097, respectively).

CONCLUSIONS

Although there are multiple fixation options for acute Rockwood type III-V AC dislocations, adding AC fixation or graft augmentation likely improves functional outcomes and decreases the CCD and recurrence rate at final follow-up-at the expense of longer operative times.

Arthroscopically Assisted Tensionable Cerclage Reconstruction of an Acromioclavicular Separation With Combined Fixation of the Coracoclavicular and Acromioclavicular Ligaments

A variety of surgical techniques are currently available to manage high-grade acromioclavicular (AC) separations, including hook plates/wires, nonanatomic ligament reconstruction, and anatomic cerclage with or without biological augmentation. Traditional reconstructions focused on the coracoclavicular ligaments alone and often were associated with high rates of recurrent deformity. Biomechanical and clinical data have suggested that additional fixation of the AC ligaments is beneficial. This Technical Note describes an arthroscopically assisted approach for combined reconstruction of the coracoclavicular and AC ligaments with a tensionable cerclage.

Treatment of Failed Coracoclavicular Ligament Reconstructions: Primary Acromioclavicular Ligament and Capsular Reconstruction and Revision Coracoclavicular Ligament Reconstruction

Acromioclavicular (AC) joint dislocations are a common injury affecting 2 of every 10,000 people in the general population and comprise 9% to 12% of all injuries to the shoulder. Most injuries occur through contact activity, which drives the acromion inferiorly with the clavicle remaining in its anatomic position, initiating a cascade of injury propagating from the AC ligament followed by failure of the coracoclavicular ligaments. Many techniques have been described for AC joint injuries, without a consensus gold standard. The revision setting offers even less consensus on treatment options and countless difficulties for surgeons. There have been more than 60 described procedures regarding AC and coracoclavicular ligament reconstructions, with significant controversy regarding the optimal intervention for each injury. When these techniques fail, it is important to pinpoint the mechanism of failure to construct a successful plan for revision. The purpose of this Technical Note is to describe our preferred method of primary AC and revision coracoclavicular reconstruction using a combination of autograft and allograft semitendinosus as well as TightRope fixation.