Unstable acromioclavicular joint injuries: Is there really a difference between surgical management in the acute or chronic setting?

Clinical and radiographic outcome after acromioclavicular reconstruction: a single-center comparison of three different techniques

This prospective, observational cohort study compares the clinical and radiographic outcomes of the modified Weaver and Dunn (WD) technique with the newer, anatomical double-button plus tendon allograft technique (DB), and the suture anchor repair plus tendon allograft (SA). The study cohort includes 53 patients, who underwent surgery for acromioclavicular joint (ACJ) dislocation Rockwood type 3, 4 and 5. Patient-reported outcome scores and clinical results, including Disabilities of the Arm, Shoulder and Hand (DASH), the Subjective Shoulder Value (SSV), the Visual Analogue Scale (VAS) and the Constant score (CS) results as well as loss of reduction rates on plain radiographs were compared. Nineteen patients in the DB group, 19 patients in the SA group and 15 patients in the WD group were included. Average time of follow up was 5 years. The mean VAS scores (SD) were 0.3 (0.6), 0.5 (0.8) and 1.2 (1.4) in the WD, DB and SA groups (p=0.06). There were no significant differences in DASH, SSV and Constant scores between groups. Loss of reduction on plain radiographs occurred in 4 patients in total (1 WD, 1 DB, 2 SA). The SSV score, the DASH score, the Constant score and the VAS-score revealed no statistically significant differences between the group with good alignment compared to groups with partial reduction or loss of reduction. In conclusion we can state that the use of anatomical reconstruction techniques with tendon allograft and additional button or suture anchors fixation does not affect the clinical and radiographical outcomes compared to the classic Weaver and Dunn procedure. Loss of reduction was not correlated to worse clinical outcome scores.

Comparison of Double Endobutton and Clavicular Hook Plate in Acromioclavicular Joint Disruption: A Systematic Review and Meta-analysis

BACKGROUND

Acromioclavicular joint (ACJ) disruptions are corrected by surgery either with an endobutton or a hook plate. The results in the long term were found to be similar in many randomized controlled trials. This study aims to conduct a meta-analysis to evaluate the functional outcome and complications of double endo button versus clavicular hook plate (CHP) for ACJ disruption (Rockwood types III-VI).

MATERIALS AND METHODS

Two authors independently searched related articles from electronic databases (PubMed, Google Scholar, MEDLINE, SCOPUS, and Web of Science) till January 26, 2022. The data were extracted from the related articles and analyzed by Stata software. For bias calculation of each study, the Newcastle-Ottawa scale and the RevMan 5.4 software were used.

RESULTS

14 cohort studies, 2 randomized control trial studies, and 1 case-control study including patients were selected in this meta-analysis. The results of our study showed a significantly higher Constant-Murley Score (WMD 5.79, 95% confidence interval [CI] 2.23-9.36), Visual Analog Scale (WMD- 0.63, 95% CI [-0.79, -0.46]) and University of California at Los Angeles shoulder score (UCLA) scale (WMD 3.32, 95% CI [2.87, 3.77]) for double endobutton group. At the same time, some complications like implant failure were more common in the double endobutton group.

CONCLUSION

This meta-analysis shows better functional and clinical outcomes of shoulder joint for the treatment of acromioclavicular joint (ACJ) disruption cases (Rockwood types III-VI) with no need for secondary operation, unlike the CHP. Complications like subacromial erosion, ACJ arthrodesis, and infection rate are higher in the CHP group, whereas the chance of implant failure is higher in the double endobutton group.

Subject-specific computational modeling of acromioclavicular and coracoclavicular ligaments

BACKGROUND

Disruption of the acromioclavicular joint is a common injury. Despite the different surgical procedures described for treating this injury, complications such as loss of reduction and failure of fixation remain unacceptably high. We developed a computer model of the acromioclavicular joint to better understand the biomechanical contributions of the ligaments that are typically injured.

METHODS

Six fresh frozen human cadaveric shoulders were tested on an AMTI VIVO 6-degree of freedom test platform to measure force-displacement in inferior translation, anteroposterior translation, and internal rotation before and after sequentially transecting the coracoclavicular and acromioclavicular ligaments. These data were used to construct computer models of each specimen. Three-dimensional computed tomographic scans were used to generate a rigid-body dynamics model using the AnyBody Modeling System. The scapula and clavicle were connected by the acromioclavicular joint capsule, the conoid ligament, and the trapezoid ligament. Subject-specific ligament properties were calculated by matching computer predictions to experimental force-displacement data.

RESULTS

The calculated free lengths of the conoid, trapezoid, and acromioclavicular ligaments were 13.5 (±3.2), 11.8 (±2.4), and 11.0 (±2.7) mm, respectively. The calculated stiffnesses of the conoid, trapezoid, and acromioclavicular ligaments were 34.3 (±6.3), 28.4 (±3.2), and 33.8 (±8.2) N/mm, respectively. Root mean square deviation (RMSD) of predicted force-displacement curves relative to experimental force-displacement curves (during inferior and anteroposterior translation) was less than 1 mm. For validation of subject-specific models, after ligament properties were calculated, the RMSD of the predicted torque over 15° of internal rotation was 12% of maximum rotational torque (average for 6 specimens).

DISCUSSION AND CONCLUSION

Acromioclavicular disruption results in multidirectional instability, which requires careful consideration of the individual contributions of the injured ligaments. In addition, variations in patient anatomy can significantly affect the biomechanical stability of the reconstruction. Subject-specific models can enhance our understanding of the individual and collective biomechanical contributions of the injured soft tissues to the multiaxial stability of the acromioclavicular joint. These models may also be useful for analyzing and assessing biomechanical stability after various types of surgical reconstruction.

Reliability of the ISAKOS Modification to Subclassify Rockwood Type III Acromioclavicular Joint Injuries

Background

To improve clinical management, the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) developed a specific subclassification of Rockwood type III acromioclavicular (AC) injuries: IIIA (no overriding distal clavicle) and IIIB (overriding distal clavicle).

Purpose/Hypothesis

The study aimed to determine the inter- and intraobserver reliability of the radiographic classification proposed by ISAKOS for AC injuries. It was hypothesized that the strength of agreement for the ISAKOS modification will be substantial to almost perfect.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

We evaluated 40 radiographs of all types of AC joint injuries from patients at a single institution. The images were distributed to 6 shoulder and elbow fellowship-trained orthopaedic surgeons, along with standardized assessment questionnaires. The evaluators measured the bilateral coracoclavicular distance and the coracoclavicular ratio and classified the severity of the injuries according to the modified ISAKOS Rockwood classification. Four of the surgeons repeated the evaluation 6 weeks later to calculate intraobserver agreement. The kappa (κ) statistic was calculated for categorical inter- and intraobserver reliability. Intraclass correlation coefficient (ICC) estimates were calculated for the reliability of the coracoclavicular distance measurement. A 2-tailed test was performed to assess statistical significance.

Results

Overall interobserver agreement was substantial (κ = 0.637; 95% CI, 0.595-0.680) among the 6 evaluators, and intraobserver agreement was also substantial among the 4 evaluators (κ = 0.616; 95% CI, 0.549-0.638). The interobserver agreement for evaluating types IIIA and IIIB was fair (κ = 0.215; 95% CI, 0.135-0.295) and moderate (κ = 0.473; 95% CI, 0.393-0.553), respectively. The agreement on the coracoclavicular distance measurements was excellent among the 6 evaluators on both the affected side (ICC, 0.982; 95% CI, 0.970-0.990) and the unaffected side (ICC, 0.930; 95% CI, 0.894-0.958).

Conclusion

Substantial agreement was found when categorizing AC joint injuries using the ISAKOS modification of the Rockwood classification, with excellent reliability demonstrated for the quantitative assessment of vertical displacement of the clavicle. Visual examination was unreliable in differentiating type IIIA injuries from type IIIB injuries.

Anatomic reconstruction of the acromioclavicular joint provides the best functional outcomes in the treatment of chronic instability

PURPOSE

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

METHODS

Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of chronic 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

Fourty-four studies were included for a total of 1020 shoulders. Mean age of participants was 38 years. Mean follow-up was 32.9 months. Arthroscopic techniques showed better results than open approach (p < 0.0001). Synthetic reconstructions demonstrated better functional outcomes compared to internal fixation and biologic techniques (p < 0.0001). Among biologic techniques, combined coracoclavicular and acromioclavicular ligaments reconstruction showed better Constant (p = 0.0270) and ASES (p = 0.0113) scores compared to isolated coracoclavicular ligaments reconstruction; anatomic biologic non-augmented graft reconstruction showed better Constant (p < 0.0001), VAS (p < 0.0001) and SSV (p = 0.0177) results compared to augmented techniques. No differences in functional outcomes could be found between anatomic biologic non-augmented graft versus synthetic reconstructions. Overall, methodological quality of the included studies was low.

CONCLUSION

Anatomic reconstructions, both synthetic and biologic, showed the best functional results.

LEVEL OF EVIDENCE

IV.

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.

[Arthroscopically-assisted treatment of acute and chronic dislocations of the acromioclavicular joint : A prospective clinical trial]

BACKGROUND

Injuries of the acromioclavicular joint (ACJ) are frequent and often occur during sports. While arthroscopically-assisted stabilization of acute injuries of the ACJ is a well-established procedure, there is not much data available for arthroscopically-assisted stabilization of chronic injuries of the ACJ.

OBJECTIVES

This study assesses clinical and radiological results of arthroscopically-assisted stabilization of acute and chronic injuries of the ACJ.

MATERIALS AND METHODS

Thirty-six patients with acute and chronic injuries of the ACJ were assessed in a prospective clinical trial. Twenty-five patients with acute injuries (group A) and eleven patients with chronic injuries (group B) were included in this study. Patients of group A were operated using two suture-button systems, while patients of group B received one suture-button system and an autologous gracilis tendon graft.

RESULTS

In group A, the mean preoperative Constant score rated 38, and the ASES score rated 34. At follow-up the Constant score (92) and the ASES score (89) had improved. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (15.8 mm) in comparison to the contralateral shoulder (10.9 mm). In group B, the preoperative Constant score measured 57. It improved to 72 points at follow-up. The ASES score improved from 39 to 72 points in the same period. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (18.9 mm) in comparison to the contralateral shoulder (12.4 mm).

CONCLUSIONS

Stabilization of acute injuries of the ACJ with two suture-button systems is related to very good shoulder function after one year. The native coracoclavicular distance cannot be restored with this procedure. Stabilization of chronic injuries of the ACJ with a suture-button system and an autologous gracilis tendon graft is related to improved shoulder function after one year. However, shoulder function cannot be fully restored with the stabilization technique presented.

Radiographic features and complications following coracoclavicular ligament reconstruction

OBJECTIVE

To report radiographic features and complications of coracoclavicular ligament reconstruction and the association of radiographic features with symptomatology.

MATERIALS AND METHODS

Retrospective picture archiving and communication system query (1/2012-8/2018) identified subjects with prior coracoclavicular ligament reconstruction. Post-operative radiographs were reviewed with attention to the following: (1) acromioclavicular alignment, (2) coracoclavicular width, (3) distal clavicular osteolysis, (4) osseous tunnel widening, and (5) hardware complication or fracture. Medical records were reviewed to determine purpose of imaging follow-up (symptomatic versus routine). Statistical analysis determined associations between binary features and outcomes, and inter-reader agreement.

RESULT

Review of 55 charts identified 32 subjects (23 male, 9 females; age range 24-64; imaged 1-34 months following surgery) meeting inclusion criteria. Loss of acromioclavicular reduction was the most common imaging finding (n = 25, 78%), with 76% progressing to coracoclavicular interval widening. Distal clavicular osteolysis was seen in 21 cases (66%) and was significantly associated with loss of acromioclavicular joint reduction (p = 0.032). Tunnel widening occurred in 23 patients (82%) with more than one follow-up radiograph. Six (19%) had hardware complication or fracture. No radiographic feature or complication had significant correlation with symptomatology (p values 0.071-0.721). Inter-reader agreement was moderate to substantial for coracoclavicular interval widening and hardware complication, fair to substantial for tunnel widening, and fair to moderate for loss of acromioclavicular reduction and distal clavicular osteolysis.

CONCLUSION

Loss of acromioclavicular joint reduction, coracoclavicular interval widening, distal clavicular osteolysis, and tunnel widening are common radiographic features after coracoclavicular ligament reconstruction; however, they do not necessarily correlate with symptomatology.

High grade acromioclavicular injury: Comparison of arthroscopic assisted acromioclavicular joint fixation and anatomic acromioclavicular joint reconstruction

Background

Injuries to the acromioclavicular (AC) joint disrupting the AC and Coracoclavicular (CC) ligaments could lead to loss of clavicular strut function. A High-grade AC joint injury remain challenging because of highly variety of treatment and limited evidence exists comparing clinical outcomes and complications after surgery.

Purpose

The purpose of this study was to compare the clinical and radiological outcome after arthroscopic assisted acromioclavicular Joint fixation and anatomic acromioclavicular joint reconstruction.

Study design

Retrospective Clinical Cohort Study.

Methods

Twenty-nine patients with a high grade (Rockwood Type III-V) Acromioclavicular Joint Injury, operatively treated with arthroscopic assisted acromioclavicular joint fixation and anatomic acromioclavicular joint reconstruction from 2012 to 2018. The clinical assessment consists of Specific AC Score (SACS) and Nottingham Score. The radiographic evaluations were performed to evaluate the stability of reduction and the complications are assessed.

Results

There were a significant different between groups with AC joint reconstruction and fixation group (20 vs. 8, p < 0.005) and (19 vs. 10, p < 0.005) in SAC score and Nottingham score, respectively. There were no significant different in CC dstance between two groups. At the last follow up 6 patient develop loss of reduction with CC percentage >50% in AC joint fixation. Complication developed in 5 patients (17%) including 2 mild osteolysis, 1 superficial infection, 1 implant failure, and 1 clavicle fracture.

Conclusion

Anatomic AC joint reconstruction was associated with functional and radiologic benefits and better restored the stability.

Acromioclavicular joint disruptions: A comparison of two surgical approaches 'hook' and 'rope'

INTRODUCTION

Acromioclavicular joint injuries are common shoulder girdle injuries most commonly resulting from a direct blow to the acromion with the arm adducted. Type-I or type-II acromioclavicular joint injuries can be managed with sling immobilization, early shoulder motion, and physiotherapy. The management of type-III injuries remains controversial and is individualized. Type IV and V injuries should be treated surgically. A myriad of surgical techniques for the management of acromioclavicular joint injuries have been reported.

METHODS

We present a comparative study of 76 patients treated with two most common modalities of treatment for AC joint disruption and that is Hook plate stabilisation (n=52) or arthroscopically assisted tight rope stabilisation (n=24). The primary objective was to establish whether hook plate stabilization was superior compared to arthroscopic tight rope fixation in reducing pain and increasing function in the short-term and long-term for patients with AC joint disruptions III-IV. We also wanted to assess how quickly patients returned to their work/job. It was a prospective study, we included all the patients operated between 2008 and 2015 for AC joint disruption by the two shoulder surgeons of our department. All patients followed a strict physiotherapy protocol and were assessed at 6 weeks, 3 months and 12 months. We used the Harm and cost criteria of assessment and the patient specific functional outcome scores.

RESULTS

Both modalities of treatment have high patient satisfaction rate, return to work is faster in tight rope group but after a year both group of patients returned to their premorbid state. Removal of hook plate is not mandatory and lysis of acromion is rare (1% in our series).

CONCLUSION

Despite the fact that both methods yielded similar results and have statistically similar number of complications, the type of postoperative complications was different between groups. The plate group had more postoperative pain and worse function but both aspects improved after plate removal. The rope group had more complex complications including deep infection and recurrence of deformity and fracture. These differences should be taken into consideration when consenting the patient regarding possible treatment.

Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques

BACKGROUND

Acromioclavicular (AC) instability is a frequent injury affecting young and athletic populations. Symptomatic, high-grade dislocations may be managed by a myriad of operative techniques that utilize different grafts to achieve reduction. Comparative data are lacking on the ability of these techniques to achieve excellent patient outcomes and stable AC reduction and to minimize complications.

PURPOSE

To systematically review the outcomes and complications of different techniques of AC joint reconstruction.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The MEDLINE, Scopus, Embase, and Cochrane Library databases were accessed to perform a systematic review of the scientific literature from 2000 to 2018 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following keywords: "acromioclavicular" and "reconstruction." Included articles were evaluated for loss of reduction, complication rate, revision rate, and change in coracoclavicular distance. Articles were stratified by graft and surgical material used: suture only, Endobutton with suture, TightRope, GraftRope, synthetic artificial ligament, tendon graft, and Weaver-Dunn coracoacromial ligament transfer. These outcomes were pooled using a random-effects model and stratified by surgical technique and arthroscopic versus open reconstruction.

RESULTS

Fifty-eight articles were included in the analysis, with 63 homogeneous populations composed of 1704 patients. The mean age was 37.1 years (range, 15-80 years) with a mean follow-up of 34.3 months (range, 1.5-186 months). The overall failure rate was 20.8% (95% CI, 16.9%-25.2%). The overall pooled complication rate was 14.2% (95% CI, 10.5%-18.8%). The most common complications were infection (6.3% [95% CI, 4.7%-8.2%]), fracture to the coracoid or distal clavicle (5.7% [95% CI, 4.3%-7.6%]), and hardware/button failure (4.2% [95% CI, 3.1%-5.8%]). There were no differences between arthroscopic and open techniques in regard to loss of reduction (P = .858), overall complication rate (P = .774), and revision rate (P = .390). Open surgery had a greater rate of clavicular/coracoid fractures than arthroscopic surgery (P = .048). Heterogeneity, best assessed from the pooled loss of reduction, was measured as I² = 64.0%.

CONCLUSION

Open and arthroscopic AC joint reconstruction techniques have no differences in loss of reduction, the complication rate, and the revision rate based on the available literature. Complications are significant, and profiles vary between surgical techniques, which should be evaluated in the decision making of selecting the technique.

Primary Acromioclavicular-Coracoclavicular Reconstruction Using 2 Allografts, TightRope, and Stabilization to the Acromion

Acromioclavicular (AC) joint injuries are a common cause of shoulder pain, particularly among young athletes participating in contact sports. Injuries to the AC joint most commonly occur from direct impact at the acromion and are classified as types I to VI. Although most AC joint injuries can be treated nonoperatively, types IV to VI are best treated with surgery, with type III being controversial and most surgeons recommending an initial trial of nonoperative treatment. Although numerous surgical techniques have been described, no gold standard technique has been established. Biomechanical testing suggests that anatomic reconstruction of both the AC and coracoclavicular ligaments results in a superior surgical construct. The objective of this Technical Note is to describe our preferred technique for the primary treatment of AC joint instability in the acute and chronic setting. Using 2 free tendon grafts in combination with a cortical button suspensory device combines the advantages of a nonrigid biologic and anatomic AC and coracoclavicular ligament reconstruction while benefiting from the strength of a cortical suspensory device in resisting displacement of the AC joint.