Prevalence and pattern of glenohumeral injuries among acute high-grade acromioclavicular joint instabilities

Arthroscopic "V" Configuration Anatomic Reconstruction of Chronic Acromioclavicular Joint Dislocations Using Double-Bundled Autogenous Gracilis Tendon Graft Reinforced With FiberTape Internal Brace

We present an arthroscopic technique for chronic acromioclavicular joint dislocations that involves reconstructing the acromioclavicular and coracoclavicular ligaments using an autogenous gracilis tendon graft reinforced with FiberTape. We describe the technique using 2 tunnels in the clavicle and a coracoid tunnel to re-create the anatomic double-bundle coracoclavicular ligaments and also reconstruct the acromioclavicular ligament, providing both horizontal and vertical stability for the acromioclavicular joint. The advantage of our technique is the reduced use of implants and also providing stable reconstruction, a good chance for tendon integration into the coracoid, and fewer recurrences due to graft stretching, enabling good stability to the joint.

Acromioclavicular joint dislocation and concomitant labral lesions: a systematic review

Acromioclavicular (AC) joint dislocations frequently co-occur with intra-articular glenohumeral pathologies. Few comprehensive studies have focused on labral tears specifically associated with AC joint trauma. This systematic review will address this gap. A comprehensive electronic search was conducted across PubMed, Cochrane Library, and Google Scholar (pages 1-20) spanning from 1976 to May 19, 2023. Seven studies met the inclusion criteria for this systematic review, consisting of three retrospective studies and four case series. These studies collectively involved 1,044 patients, of whom 282 had concomitant labral lesions. The pooled prevalence of intra-articular labral injuries associated with acute AC joint dislocation was 27%. The prevalence of these labral lesions varied significantly between studies, ranging from 13.9% to 84.0% of patients, depending on the study and the grade of AC joint dislocation. Various types of labral tears were reported, with superior labrum anterior to posterior (SLAP) lesions being the most common. The prevalence of SLAP lesions ranged from 7.2% to 77.4%, with higher grades of AC joint dislocations often associated with a higher prevalence of SLAP tears. Moreover, grade V dislocations exhibited a complete correlation with SLAP tears. The studies yielded contradictory findings regarding older age and higher grades of AC joint dislocation as risk factors for concurrent labral lesions. This review underscores the frequent association between labral lesions and AC joint dislocations, particularly in cases of lower-grade injuries. Notably, SLAP lesions emerged as the predominant type of labral tear.

Management of Acute High-Grade Acromioclavicular Joint Dislocations: Comparable Clinical and Radiological Outcomes After Bidirectional Arthroscopic-Assisted Stabilization With the Single Low-Profile Suture Button Technique Versus Double-Suture Button Technique

PURPOSE

To compare the 2-year clinical and radiological outcomes of an arthroscopic-assisted bidirectional stabilization procedure using a single low-profile (LPSB) or double-suture button (DSB) technique with additional percutaneous acromioclavicular (AC) cerclage fixation for patients with acute high-grade AC joint dislocation.

METHODS

This retrospective cohort study compared male patients aged between 18 and 56 years with acute high-grade AC joint dislocation fixed with either a LPSB or DSB technique. Patients were examined at least 24 months after surgery. Subjective Shoulder Value (SSV), Taft (TF), and Acromioclavicular Joint Instability (ACJI) scores were evaluated. Coracoclavicular difference, ossification, AC joint osteoarthritis, and dynamic posterior translation (DPT) were assessed on bilateral anteroposterior stress radiographs and modified Alexander views. The revision rate due to implant conflict and duration of surgery were reported. Group outcome differences were analyzed using standardized hypothesis tests.

RESULTS

28 patients aged 39.2 (LPSB) and 36.4 years (DSB) (P = .319; CI: -2.77-8.34) were eligible per cohort. The follow-up was 30.5 (LPSB) and 37.4 months (DSB) (P = .02; CI: -12.73-1.08). LPSB patients rated a significantly higher SSV (93.2% vs 81.9% [DSB]; P = .004). TF and ACJI scores were similar between the groups. Coracoclavicular difference markedly decreased from 12 mm to 3 mm for both cohorts (P < .001). Ossification was identified in over 85% in both cohorts (P = .160; CI -0.77-0.13) and osteoarthritis in 21.4% (LPSB) and 39.3% (DSB) (P = .150). Persistent DPT was found in around 30% for both cohorts (P = .561; CI -0.26-0.48). The revision rates were 0% (LPSB) and 7% (DSB) (P = .491). LPSB surgery was shorter (59.7 vs 71.5 mins [DSB]) (P = .011).

CONCLUSIONS

The results of the LPSB and DSB techniques with additional percutaneous AC cerclage fixation showed comparable outcomes with excellent clinical and satisfactory radiological results. The assessment of the subjective patient satisfaction was in favor of the LPSB technique and no postoperative revision event was observed following this procedure.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Simultaneous acromioclavicular dislocation, proximal humeral fracture, and reverse Hill-Sachs lesion: a case report

BACKGROUND

In cases with injuries to the shoulder region, the combination of acromioclavicular joint dislocation, reverse Hill-Sachs lesion, and proximal humeral fracture is a very rare condition.

CASE PRESENTATION

This study described a 38-year-old male Persian patient with simultaneous acromioclavicular joint dislocation, proximal humeral fracture, and reverse Hill-Sachs lesion due to motor vehicle crash injury who underwent arthroscopic acromioclavicular joint fixation using tight rope technique. In the 7-month follow-up period following the surgical fixation, range of motion was approximately normal. Reduction and hardware were intact, no dislocation or apprehension to dislocation was observed. Patient only had minor shoulder pain at the end of range of motion and a dull pain on the site of incision over the clavicle in deep touch. Our findings showed acceptable arthroscopic outcomes in the management of such complex case.

CONCLUSION

Our experience on this case showed acceptable outcomes of the arthroscopic treatment of the acromioclavicular joint dislocation in the management of such a complex case with associated injuries to the shoulder region.

Clavicular hook plate versus dog-bone technique for acute high-grade acromioclavicular joint dislocation: a retrospective cohort study comparing clinical outcome scores, complications, and costs

INTRODUCTION

Arthroscopically assisted coracoclavicular (CC) ligament fixation techniques have been promoted as providing superior outcomes for the treatment of acute high-grade acromioclavicular joint (ACJ) dislocations. Nevertheless, there is a lack of high-level evidence for clinically relevant benefits. At our institute, orthopaedic surgeons use an arthroscopically assisted coracoclavicular ligament fixation technique (DB), while general trauma surgeons use a clavicular hook plate (cHP) technique. The aim of the study was to compare clinical outcomes, complication rates, and costs between the two groups.

MATERIALS AND METHODS

The hospital database was searched for patients treated for acute traumatic high-grade (Rockwood Typ ≥ III) ACJ dislocation using either a cHP or arthroscopically assisted DB technique between 2010 and 2019. Seventy-nine patients could be included (56 patients in the cHP group and 23 in the DB group). QuickDASH scores, subjective shoulder value (SSV) scores, pain scores (numerical pain rating scale 10), and complication rates were retrospectively collected through phone interviews and by screening patient charts as well as surgical reports. Costs per patient were obtained from the hospital's accounting system.

RESULTS

Mean follow-up was 54 ± 33.7 and 45 ± 21.7 months in the cHP and DB group, respectively. QuickDASH and SSV scores did not differ, but patients in the cHP group reported significantly lower pain scores (p = 0.033). More patients reported hypertrophic or disturbing scars (p = 0.49) and sensibility disturbances (p = 0.007) in the cHP group. Three patients suffered from a frozen shoulder in the DB group (p = 0.023).

CONCLUSION

Patient-reported outcomes are excellent after long-term follow-up for both techniques. There are no clinically relevant differences in clinical outcome scores based on our results and a review of the literature. Both techniques certainly have their benefits regarding secondary outcome measures.

LEVEL OF CLINICAL EVIDENCE

Level 3, retrospective cohort study.

Acromioclavicular Joint Injuries in Sport

ABSTRACT

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

No difference in clinical outcome at 2-year follow-up in patients with type III and V acromioclavicular joint dislocation treated with hook plate or physiotherapy: a randomized controlled trial

BACKGROUND

The need for operative treatment of acute acromioclavicular (AC) joint dislocation is unclear. The purpose of this randomized controlled trial was to compare the outcomes after operative treatment with a hook plate with the outcomes after nonoperative treatment of acute Rockwood type III and type V AC joint dislocations separately.

METHODS

The inclusion criteria were patients aged 18-65 years with an acute type III or type V AC joint dislocation with the availability to start treatment within 3 weeks after trauma. All patients received the same standardized outpatient rehabilitation protocol and were followed up for 24 months. Assessments were based on radiographs, clinical examination findings, and questionnaires. The primary outcome was the Constant score (CS). The secondary outcomes were as follows: Subjective Shoulder Value (SSV), QuickDASH score (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire), shoulder pain at rest and during movement rated using a visual analog scale, EQ-5D (European Quality of Life 5 Dimensions) score, patient satisfaction, cosmesis, complications, and adverse events. The 4 groups were compared using 1-way analysis of variance and intention to treat.

RESULTS

The included patients (N = 124) (mean age, 40 years [range, 18-64 years]; 91% male patients) were randomized, stratified by type, to nonoperative treatment (type III, n = 33; type V, n = 30) or operative treatment with a hook plate (type III, n = 30; type V, n = 31) at a single center. Three patients randomized to physiotherapy dropped out before any follow-up measures, leaving 121 patients in the study. Complete clinical follow-up data were obtained from 118 patients at 24 months. At 3 months, patients in both nonoperatively treated groups had a significantly better mean CS, SSV, and QuickDASH score and had less pain at rest and during movement compared with patients treated operatively. At 6, 12, and 24 months, there were no significant differences in the CS, SSV, QuickDASH score, pain, or EQ-5D score between the groups regardless of intervention. At 24 months, the mean CS was 88 for nonoperatively treated type III patients vs. 91 for operatively treated type III patients and was 90 vs. 91 for type V patients (P = .477). At final follow-up, patients had regained 97% of the mean CS comparing the uninjured and injured shoulders and 86% of the patients rated the result as excellent or good. Eleven patients assigned to nonoperative treatment (18%, 6 type III and 5 type V) underwent surgery within 19 months.

CONCLUSIONS

Both the nonoperative and operative treatment groups had very good restoration of shoulder function and patient satisfaction at 24 months, and operative treatment did not lead to better outcomes compared with nonoperative treatment. In conclusion, our study does not support surgery with a hook plate in patients with acute Rockwood type III or type V AC joint dislocations.

Arthroscopically assisted single tunnel reconstruction for acute high-grade acromioclavicular joint dislocation with an additional acromioclavicular joint cerclage

PURPOSE

Purpose of this study was to demonstrate that a single tunnel reconstruction of high-grade acromioclavicular (AC) joint instabilities with implants of the second generation is sufficient for stabilisation, especially in combination with an AC cerclage.

METHODS

Patients with an acute AC-joint dislocation type Rockwood III-B and V were included. Besides clinical follow-up examination, radiographs were analysed. The functional outcome measures were Constant Score (CS), Taft score (TS), ACJI score and patient's satisfaction. Horizontal instability was evaluated by clinical examination and radiological with an Alexander view.

RESULTS

Thirty-five patients with a mean follow-up of 29 months were included. Ninety-seven per cent were satisfied with their result, with an average Subjective Shoulder Value of 90%. The CS averaged at 90 ± 10 points, TS at 11 ± 1 points and ACJI at 78 ± 18 points. Radiologically, 3 of 29 patients (10%) showed a persisting horizontal instability. The coracoclavicular (CC) distance improved from 22 preoperative to 10 mm postoperative, which was comparable to the contralateral side (10 mm, p = 0.103). At follow-up the CC distance increased to 13 mm (p = 0.0001).

CONCLUSION

AC-joint stabilisation with a single tunnel reconstruction using a second-generation implant results in good to excellent clinical results with high patient satisfaction. The additional AC augmentation improves stability in horizontal instable AC-joints and is recommended in all high-grade AC joint stabilisations. Nonetheless, reduction was slightly lost over time due to an elongation or suture failure of the coraco-clavicular fixation.

LEVEL OF EVIDENCE

IV.

Arthroscopic Anatomical Acromioclavicular Joint Reconstruction using a Button Device and a Semitendinosus Graft

Objective

To report a new technique for anatomical acromioclavicular (AC) joint reconstruction.

Methods

In order to minimize such complications, the authors describe a new anatomical and biological AC joint repair. This technique aims to provide greater stability by using two anatomically placed clavicular tunnels and a combined construct with a double endobutton cortical fixation for primary stabilization, and to be biologically advantageous by using an autologous semitendinosus (ST) tendon graft. Additionally, the coracoclavicular ligament reconstruction is complemented with an AC joint cerclage and capsular reinforcement, which will protect the biological construction in its initial stage of healing.

Results

This technique provides adequate primary and secondary biomechanical stability by passing both a semitendinosus autogenous graft and a double endobutton device, through anatomically placed and small diameter clavicle holes, without the need for coracoid drilling. Our technique showed encouraging results regarding pain resolution, range of motion, and function. At final follow‐up we experienced excellent results with average pain score of 1.6, and average ROM of 159° of forward flexion, 160° of abduction, 68° of external rotation, and internal rotation level at T11. Postoperative function also showed great improvements with average ASES of 85 points, an average Constant Score of 87 and a Subjective Shoulder Value of 89 points. This technique also achieved perfectly acceptable radiographic results, with an average coracoclavicular distance increase of 0.8 mm. Regarding complications, our sample showed one case of AC join subluxation, two cases of internal saphenous nerve injury, and two partial graft tears at the suture‐button interface, with none of these requiring surgical revision.

Conclusion

This technique is advantageous in treatment of acromioclavicular joint dislocation and can be performed in both the subacute and chronic setting.

The prevalence of intraarticular associated lesions after acute acromioclavicular joint injuries is 20%. A systematic review and meta-analysis

PURPOSE

To synthesise the evidence on the prevalence of associated intraarticular lesions in subjects with acute acromioclavicular joint (ACJ) dislocations.

METHODS

A search in two electronic databases (PUMBMED and EMBASE) was performed from 1985 to 2019. Two independent reviewers selected studies that complied with the following inclusion criteria: (1) the study included data on surgically treated ACJ dislocation grade III-V in the Rockwood classification, (2) the ACJ injuries were acute (the surgery was performed less than 6 weeks after injury), (3) an arthroscopic evaluation of the glenohumeral joint was performed during surgery. The quality of the studies included was assessed using the tool of the Joanna Briggs Institute.

RESULTS

A total of 47 studies with acute ACJ injuries met the initial inclusion criteria. Of these, 21 studies (9 retrospective case series, 9 prospective case series and 3 retrospective cohort studies) presented data on associated intraarticular lesions amenable for use in the meta-analysis. The meta-analysed studies included a total of 860 subjects with acute ACJ dislocations with a male/female ratio of 6.5 and a mean age of 32 years. The meta-analysis showed a prevalence of associated intraarticular lesions in subjects with acute ACJ of 19.9% (95% confidence interval [CI] 14.0-26.4%; 21 studies, 860 analysed participants; P = 0.000; I²: 74.5% random-effects model; low risk of bias).

CONCLUSION

One in five subjects with surgically treated acute ACJ dislocations will have an associated intraarticular lesion that requires further intervention. The case for a customary arthroscopic evaluation of the joint, even when an open procedure is performed to deal with the ACJ dislocation, is strong. Level of evidence IV Trial registry Systematic review registration number: PROSPERO CRD42018090609.

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up

PURPOSE

To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.

METHODS

A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated.

RESULTS

There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated.

CONCLUSIONS

AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction.

LEVEL OF EVIDENCE

IV (Case Series).

High Prevalence of Superior Labral Anterior-Posterior Tears Associated With Acute Acromioclavicular Joint Separation of All Injury Grades

Background

Despite the relatively high number of cases of acromioclavicular joint (AC) separation in the athletic population, optimal clinical outcomes are not achieved in every case. Limited data exist regarding the prevalence of intra-articular glenohumeral pathologies (IAPs) associated with acute AC separation of all injury grades.

Purpose

To determine the prevalence of IAPs associated with AC separation, regardless of severity.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 62 patients (mean age, 37.6 years) with acute AC separation were included in this study; 41 were nonoverhead recreational athletes. All patients underwent magnetic resonance arthrography (MRA) to evaluate for IAPs. Arthroscopic data from patients undergoing surgical treatment were correlated with MRA results.

Results

Patients sustained acute AC separation of Rockwood grade 1 (16.1%), grade 2 (46.8%), grade 3 (25.8%), and grade 4 (11.3%). A concomitant IAP was present in 48 of 62 (77.4%) patients and included superior labral anterior-posterior tears (72.6%), anterior labral tears (24.2%), posterior labral tears (4.8%), supraspinatus tears (3.2%), and inferior glenohumeral ligament ruptures (1.6%). There were 18 (29.0%) patients who had a concomitant pathology in >1 intra-articular structure (combined IAPs). Additionally, 71.8% of patients with grade 1 and 2 AC separation had associated IAPs, and 23.1% had combined IAPs. Furthermore, in patients younger than 40 years, 64.0% of those with grade 1 to 3 AC separation demonstrated associated labral pathologies. There was no difference when comparing age or severity of AC separation and the prevalence of concomitant labral tears (P = .36 and .22, respectively).

Conclusion

There was a high prevalence of IAPs among patients undergoing MRA after AC separation. While an IAP has been described in association with high-grade AC separation previously, the high prevalence of IAPs in low-grade separation in our study was unexpected and suggests that a thorough evaluation and clinical follow-up for patients with all grades of AC separation may be beneficial.

Simultaneous Posterior Shoulder Dislocation and Acromioclavicular Joint Separation: Single-Stage Arthroscopic Treatment of Combined Injuries: A Case Report

CASE

We report on a patient who received arthroscopic treatment after a unique traumatic combined injury comprising a posterior shoulder dislocation with posterior labrum damage, a reverse Hill-Sachs lesion, and a concomitant Rockwood type-V acromioclavicular joint dislocation.

CONCLUSION

Arthroscopy was applied to address all pathologies in a single-stage procedure. The outcome of reduced operating and patient recovery time suggests that our intervention is ideal for this specific indication.

Early clinical results of minimally invasive coracoclavicular ligament reconstruction can be maintained at a minimum of five years' follow-up

AIMS

There is a lack of long-term data for minimally invasive acromioclavicular (AC) joint repair. Furthermore, it is not clear if good early clinical results can be maintained over time. The purpose of this study was to report long-term results of minimally invasive AC joint reconstruction (MINAR) and compare it to corresponding short-term data.

METHODS

We assessed patients with a follow-up of at least five years after minimally invasive flip-button repair for high-grade AC joint dislocation. The clinical outcome was evaluated using the Constant score and a questionnaire. Ultrasound determined the coracoclavicular (CC) distance. Results of the current follow-up were compared to the short-term results of the same cohort.

RESULTS

A total of 50 patients (three females, 47 males) were successfully followed up for a minimum of five years. The mean follow-up was 7.7 years (63 months to 132 months). The overall Constant score was 94.4 points (54 to 100) versus 97.7 points (83 to 100) for the contralateral side showing a significant difference for the operated shoulder (p = 0.013) The mean difference in the CC distance between the operated and the contralateral shoulder was 3.7 mm (0.2 to 7.8; p = 0.010). In total, 16% (n = 8) of patients showed recurrent instability. All these cases were performed within the first 16 months after introduction of this technique. A total of 84% (n = 42) of the patients were able to return to their previous occupations and sport activities. Comparison of short-term and long-term results revealed no significant difference for the Constant Score (p = 0.348) and the CC distance (p = 0.974).

CONCLUSION

The clinical outcome of MINAR is good to excellent after long-term follow-up and no significant differences were found compared to short-term results. We therefore suggest this is a reliable technique for surgical treatment of high-grade AC joint dislocation. Cite this article: Bone Joint J 2020;102-B(7):918-924.

Low prevalence of relevant associated articular lesions in patients with acute III-VI acromioclavicular joint injuries

PURPOSE

To define the prevalence of associated articular injuries in patients with severe (Rockwood's III-VI) acute acromioclavicular joint injuries and to find out how many of these were associated with the traumatic event and required surgical treatment.

METHODS

Retrospective observational multicentric study performed in ten centres included patients who required surgery for acute acromioclavicular joint injuries between 2010 and 2017. The inclusion criteria were: presence of an acute acromioclavicular joint injury (grades III-IV-V-VI) and surgical treatment within 3 weeks of injury that included a full arthroscopic evaluation of the shoulder. Basic epidemiological data, severity of the original injury, prelesional sport level and prelesional work site requirements were recorded. The presence of intraarticular glenohumeral lesions and information of their characteristics, treatment, and whether each lesion was considered acute or pre-existing was also recorded.

RESULTS

Two-hundred one subjects [mean (SD) age 36.7 (11.7) years] with acute acromioclavicular joint injuries (110 Rockwood type III, 34 type IV, 56 type V and 1 type VI) fulfilled the inclusion criteria. A total of 28 (13.9%) associated articular lesions were found. These lesions were more often found in grade IV injuries (26.5% in grade IV vs 11.4% in grade III, p = 0.037) and presented in males (18.7% in males vs 4% in females, p = 0.015). Age, laterality, sport level or work requirements did not affect the prevalence of associated lesions. Twelve were rotator cuff tears (6 PASTA lesions, 3 partial supscapularis tears, 2 bursal supraspinatus tears and 1 full-thickness supraspinatus tear), 16 were labral tears (9 anterior, 1 posteroinferior and 6 SLAP). Only 14 (50% of lesions, 7% of total subjects) were considered acute and all but one (an SLAP type 2 tear) required further surgical attention. Most pre-existing lesions were left untreated (n = 7) or managed with minimal debridement (n = 6), and only two required further surgery. The prevalence of associated lesions that required surgical management was 7.46%.

CONCLUSIONS

The prevalence of relevant associated lesions in subjects with acute grade III to VI ACJI is relatively low. Only 14% of subjects have an associated lesion and only half of these required further surgical attention.

LEVEL OF EVIDENCE

Retrospective case series, level IV.

Acromioclavicular Joint Injuries: Evidence-based Treatment

Injuries to the acromioclavicular (AC) joint are common in the athletic patient population. Most AC joint injuries occur in young males, typically from a direct fall onto the superior aspect of the shoulder when the arm is adducted. Numerous publications describing joint anatomy and biomechanics, surgical techniques for reconstruction, and rehabilitation protocols are available to guide treatment strategies for injuries to the AC joint. Treatment is typically nonsurgical for type I and II injuries and surgical for type IV and VI injuries. Controversy surrounds the indications for nonsurgical versus surgical treatment of type III and V injuries. Multiple surgical techniques have been described, including coracoclavicular (CC) screw fixation, coracoacromial ligament transfer, and numerous methods of CC ligament reconstruction. Anatomic CC ligament reconstruction can be performed either open or arthroscopically, with and without graft augmentation. This article will discuss clinically relevant anatomy and biomechanical properties of the AC joint and will review decision-making principles and treatment options for common AC joint injuries. An updated summary of clinical outcomes after AC joint treatment will also be presented.

Percutaneous endobutton fixation of acute acromioclavicular joint injuries and lateral clavicle fractures

INTRODUCTION

This paper describes a novel technique developed by the senior author to address acute acromioclavicular joint (ACJ) dislocations and certain distal clavicle fractures.

METHODS

The procedure employs a four strand, single tunnel, double endobutton repair performed entirely percutaneously, without any arthroscopic guidance or deep surgical dissection.

RESULTS

We present the preliminary results from our series of 6 consecutive patients performed over a period of 18 months. The mean length of surgery was 36min (range 32-40) and the mean correction of coracoclavicular (CC) distance achieved was 12.6 mm (range 10.3-14.1). There was no restriction of movement in any of the patients post-operatively and their average QuickDASH scores at final follow-up was 4.2 (range 0-6.8).

CONCLUSION

Results in the present series were at least comparable to those for other techniques, validating percutaneous treatment as a solution for acute ACJ dislocations.

Surgical Volume and Postoperative Complications of Acromioclavicular Joint Separations: Analysis of the ABOS Part II Examination

BACKGROUND

High-grade acromioclavicular (AC) joint separations are relatively rare injuries that are often treated surgically, yet more information is needed about the risks of various surgical procedures in terms of considering and counseling patients regarding operative versus nonoperative treatment.

PURPOSE

To calculate whether the volume of surgical treatment of AC joint separations increased over a recent 12-year period; to examine the nature and frequency of complications, reoperations, and readmissions associated with these procedures; and to assess whether patient- and surgeon-specific factors or surgical technique affected these rates.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The American Board of Orthopaedic Surgery (ABOS) database for orthopaedic surgeons taking the Part II examination was reviewed from 2005 to 2016 to identify surgical treatment of AC joint separations. The authors calculated the percentage of all surgical cases in the ABOS database and rates of complications, reoperations, and readmissions. Association of these sequelae with patient- and surgeon-specific factors and surgical techniques was assessed.

RESULTS

There was no difference in the number or percentage of cases per year over the study period. There was an overall complication rate of 24.5%, a reoperation rate of 7.3%, and a readmission rate of 1.9%. Patients ≥40 years of age had significantly higher complication, reoperation, and readmission rates as compared with patients <40 years of age. There were significant differences in complication, reoperation, readmission, and displacement rates dependent on the type of surgical procedure performed. The highest complication rates were seen with open suspensory fixation, screw fixation, open reduction internal fixation, and arthroscopic coracoclavicular ligament repair or reconstruction. The highest reoperation rates were seen with screw fixation, open reduction internal fixation, and open suspensory fixation.

CONCLUSION

The volume of surgical treatment for AC joint separations did not change significantly over the study period. Complication, reoperation, and readmission rates were dependent on the type of surgical procedure performed and patient age. This information should assist surgeons in discussing risks when considering and counseling patients regarding operative versus nonoperative treatment.

Stabilization of Acute High-Grade Acromioclavicular Joint Separation: A Prospective Assessment of the Clavicular Hook Plate Versus the Double Double-Button Suture Procedure

BACKGROUND

The stabilization strategy for acute high-grade acromioclavicular (AC) joint separations with AC-stabilizing clavicular hook plate (cHP) or coracoclavicular (CC)-stabilizing double double-button suture (dDBS) is still under consideration.

HYPOTHESIS

The CC-stabilizing dDBS is superior to the cHP according to an AC-specific radiologic assessment and score system.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Seventy-three consecutive patients with acute high-grade AC joint separation were prospectively followed in 2 treatment groups (64.4% randomized, 35.6% patient-selected treatment): open reduction and cHP (cHP group) or arthroscopically assisted dDBS (dDBS group) performed within 14 days of injury. Patients were prospectively analyzed by clinical scores (Taft, Constant score [CS], numeric analog scale for pain) and AC-specific radiographs (AC distance, CC distance [CCD], relative CCD [rCCD; 100 / AC distance × CCD]) at points of examination (preoperative and 6, 12, and 24 months). The minimal clinically important differences (MCIDs) were assessed by the anchor-based method.

RESULTS

Twenty-seven of 35 patients (mean age ± SD: 37.7 ± 9.7 years) after cHP implantation and 29 of 38 patients (34.2 ± 9.7 years) after dDBS implantation were continuously followed until the 24-month follow-up. All patients showed significantly increased scores after surgery as compared with preoperative status (all P < .05). As compared with GI, GII had significantly better outcomes at 24 months (Taft: cHP = 9.4 ± 1.7 vs dDBS = 10.9 ± 1.1, P < .05, MCID = 2.9; CS: cHP = 90.2 ± 7.8 vs dDBS = 95.3 ± 4.4, P < .02, MCID = 16.6) and at 24 months for Rockwood IV/V (Taft: cHP = 9.4 ± 1.7 vs dDBS = 11.1 ± 0.8, P < .0005; CS: cHP = 90.1 ± 7.7 vs dDBS = 95.5 ± 3.1, P < .04). Clinically assessed horizontal instability persisted in 18.52% (GI) and 6.89% (GII; P = .24). The rCCD showed equal loss of reduction at 24 months (GII = 130.7% [control = 111%] vs GI = 141.8% [control = 115%], MCID = 11.1%).

CONCLUSION

This prospective study showed significantly superior outcomes in all clinical scores between GII and GI. The subanalysis of the high-grade injury type (Rockwood IV/V) revealed that these patients showed significant benefits from the dDBS procedure in the clinical assessments. The cHP procedure resulted in good to excellent clinical outcome data and displayed an alternative procedure for patients needing less restrictive rehabilitation protocols.

Anatomic Tunnel Placement Is Not Feasible by Transclavicular-Transcoracoid Drilling Technique for Coracoclavicular Reconstruction: A Cadaveric Study

PURPOSE

To evaluate the feasibility of anatomic tunnel placement by a transclavicular-transcoracoid drilling technique and with reference to the coracoclavicular ligaments' insertional anatomy and their orientations.

METHODS

We used 12 fresh-frozen human cadaveric shoulders (6 matched pairs; mean age, 70 years; age range, 51-82 years) to simulate intraoperative tunnel placement with the transclavicular-transcoracoid drilling technique. After both the conoid and trapezoid ligaments were identified, two 2.5-mm guide pins were inserted from the clavicle to the coracoid, passing the centers of the clavicular and coracoid insertions of the conoid and the trapezoid ligaments, in a collinear fashion to the orientation of both ligaments. The entry point of the drill at the clavicle and the exit point at the coracoid undersurface, as well as the tunnel orientations, were measured. Complications due to the procedure, including a breach of the bone cortex of the clavicle and/or coracoid process, were recorded.

RESULTS

The transclavicular-transcoracoid drilling technique for anatomic conoid ligament tunnel placement resulted in a medial cortical breach at the coracoid process in 6 of 12 shoulders. In the remaining 6 shoulders without a breach, the distance of the exit point from the medial cortex of the inferior coracoid process was only 3.6 ± 4.3 mm. For anatomic trapezoid ligament tunnel placement, no medial cortex breaching at the coracoid process occurred. However, the distance of the exit point was 3.1 ± 4.2 mm, indicating an eccentric location to the medial cortex of the coracoid process, similar to the conoid ligament.

CONCLUSIONS

This cadaveric study showed that anatomic tunnel placement by the transclavicular-transcoracoid drilling technique would not be feasible without breaching or almost breaching the medial cortex of the coracoid process.

CLINICAL RELEVANCE

The transclavicular-transcoracoid drilling technique for CC ligament reconstruction may not reproduce the anatomy of the CC ligaments but may place the coracoid process at high risk of fracture during tunnel placement.

[Current aspects and new techniques in dislocation of the shoulder joint]

With 12% of all injuries concerning the shoulder, acromioclavicular (AC) joint dislocations are a common injury especially in young and active patients. The Rockwood classification is widely accepted, which differentiates between six types depending on the degree of injury and the vertical dislocation. Because the classification does not adequately address the horizontal instability, its benefits are questionable and there is currently no consensus. For this reason, the classification and the therapy of these injuries are increasingly becoming the subject of scientific investigations. Whereas conservative treatment for type I and II injuries and operative treatment for type IV-VI injuries are widely accepted, there is still no agreement in treating type III lesions. The goal of this review article is to present the current evidence for the diagnostics, different classifications and therapeutic possibilities.

Concomitant intra-articular glenohumeral injuries in displaced fractures of the lateral clavicle

PURPOSE

To detect concomitant intra-articular glenohumeral injuries, in acute displaced fractures of the lateral clavicle, initially missed due to unfeasible clinical evaluation of the acutely injured shoulder.

METHODS

All patients suffering from an acute displaced lateral clavicle fracture with indication to surgical treatment underwent diagnostic shoulder arthroscopy prior to open reduction and internal fixation. In case of therapy-relevant intra-articular glenohumeral injuries, subsequent surgical treatment was performed.

RESULTS

Intra-articular injuries were found in 13 of 28 patients (46.4 %) with initially suspected isolated lateral clavicle fracture. Additional surgical treatment was performed in 8 of 28 cases (28.6 %). Superior labral anterior-posterior (SLAP) lesions were observed in 4 of 28 patients (14.3 %; SLAP II a: 1; II b: 1; III: 1; and IV: 1). Lesions of the pulley system were found in 3 of 28 patients (10.7 %; Habermeyer III°). One partial articular supraspinatus tendon avulsion lesion (3.6 %) and one lesion of the subscapularis tendon (3.6 %; Fox and Romeo II°) were observed.

CONCLUSIONS

Traumatic concomitant glenohumeral injuries in lateral clavicle fractures seem to be more frequent than expected in general. Subsequent surgical treatment of these formerly missed but therapy-relevant injuries may increase functional outcome and reduce complication rate.

LEVEL OF EVIDENCE

IV.

Sports activity after anatomic acromioclavicular joint stabilisation with flip-button technique

PURPOSE

Sports activity after surgical AC joint stabilisation has not been comprehensively evaluated to date. The aim of this study was to determine rate, level and time to return to sports after AC joint stabilisation and to identify the influence of overhead sports on post-operative sports activity.

METHODS

In this retrospective case series, a total of 68 patients with a high-grade AC joint dislocation (Rockwood type V) were stabilised using a single TightRope technique. Fifty-five patients (80.9 %) with median age of 42.0 (range, 18-65) years completed questionnaires regarding sports activity before and after surgery. Clinical outcome and complications were also evaluated. Forty-three patients participated in sports regularly before injury. Their sports activity was rated according to Allain, and non-overhead and overhead sports were differentiated.

RESULTS

At median follow-up of 24 (18-45) months, 41 of 43 patients (95.3 %) had returned to sports. 63 % returned to the same sports activity as before injury. 16.3 % needed to adapt the type of sports to reduce demanding activities. 11.6 % reduced the frequency and 32.5 % the intensity of sports. The median time to return to sports was 9.5 (3-18) months. Overhead athletes (Allain Type III and IV) had to reduce their sports activity significantly more often (11.8 vs. 53.8 %; p = 0.011) and needed more time to return to sports (9.5 vs. 4.5 months; p = 0.009).

CONCLUSION

After stabilisation of AC joint dislocation, the majority of patients returned to sports after a substantial period of time. Overhead athletes, in particular, required more time and had to considerably reduce their sports activity. The findings impact therapeutic decision-making after AC joint injury and help with the prognosis and assessment of rehabilitation progress.

LEVEL OF EVIDENCE

IV.

Concomitant glenohumeral pathologies associated with acute and chronic grade III and grade V acromioclavicular joint injuries

PURPOSE

The purpose of this study was to identify the risk of concomitant glenohumeral pathologies with acromioclavicular joint injuries grade III and V.

METHODS

Patients who underwent arthroscopically-assisted stabilization of acromioclavicular joint injuries grade III or grade V between 01/2007 and 12/2015 were identified in the patient databases of two surgical centres. Gender, age at index surgery, grade of acromioclavicular joint injury (Rockwood III or Rockwood V), and duration between injury and index surgery (classified as acute or chronic) were of interest. Concomitant glenohumeral pathologies were noted and their treatment was classified as debridement or reconstructive procedure.

RESULTS

A total of 376 patients (336 male, 40 female) were included. Mean age at time of arthroscopic acromioclavicular joint reconstruction surgery was 42.1 ± 14.0 years. Overall, 201 patients (53%) had one or more concomitant glenohumeral pathologies. Lesions of the biceps tendon complex and rotator cuff were the most common. Forty-five patients (12.0%) had concomitant glenohumeral pathologies that required an additional repair. The remaining 156 patients (41.5%) received a debridement of their concomitant pathologies. Rockwood grade V compared to Rockwood grade III (p = 0.013; odds ratio 1.7), and chronic compared to acute injury were significantly associated with having a concomitant glenohumeral pathology (p = 0.019; odds ratio 1.7). The probability of having a concomitant glenohumeral pathology was also significantly associated with increasing age (p < 0.0001).

CONCLUSIONS

Concomitant glenohumeral pathologies were observed in 53% of surgically treated patients with an acute or chronic acromioclavicular joint injury of either grade III or V. Twenty-two percent of these patients with concomitant glenohumeral pathologies received an additional dedicated repair procedure. Although a significant difference in occurrence of concomitant glenohumeral pathologies was seen between Rockwood grades III and V, and between acute and chronic lesions, increasing age was identified as the most dominant predictor.

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Reconstruction After Acute Acromioclavicular Separation Injuries

Acute acromioclavicular (AC)-joint dislocations are common injuries of the shoulder girdle. Surgical repair is indicated for acute high-grade (Rockwood types IV, V, and VI) AC-joint injuries. The best treatment for type III is still controversial, but young and active patients with this type of injury might benefit from a surgical AC-joint stabilization. Surgery should be performed within the first 3 weeks after the injury since the biological healing potential decreases with time. Acute AC-joint separation is diagnosed by clinical examination and radiography. Vertical translation anteroposterior stress views with a 10-kg load are used to grade the injuries. Bilateral lateral stress (Alexander) views are used to evaluate dynamic horizontal translation qualitatively. Arthroscopic techniques for AC reconstruction have become more popular in recent years because they are minimally invasive; they allow treatment of concomitant glenohumeral lesions; and they can be performed in one step, with insertion of implants that do not have to be removed later. The arthroscopically assisted double-button technique with an additional AC cerclage was developed to stabilize the AC joint by internal bracing of the torn ligaments. The procedure consists of the following steps. Step 1: With the patient in the beach-chair position, a 2-cm incision is made on top of the clavicle and posterior and lateral viewing portals as well as an anteroinferior working portal are created. Step 2: With the arthroscope in the lateral portal, the subcoracoid bursa and the base of the coracoid are dissected with a radiofrequency ablation device through the anteroinferior portal. Step 3: Coracoclavicular drilling is done with use of a drill guide and under arthroscopic and image-intensifier control. After overdrilling of the Kirschner wires, Nitinol suture passers are introduced and retrieved via the anteroinferior portal. Step 4: Transclavicular and transacromial drill-holes are established for the AC cerclage. Step 5: The 2 double-button devices are attached to the Nitinol suture passers, and the inferior buttons are shuttled through the clavicle and coracoid and then placed parallel to the coracoid base. Step 6: The sutures are tightened, and an anatomical vertical reduction of the AC joint is achieved. Step 7: A triangular acromioclavicular nonabsorbable cerclage tape is used for horizontal stabilization. Step 8: The clavicular incision is closed in 2 layers, including the repair of the deltotrapezoidal fascia and the arthroscopic portals, in a standard fashion. The combined arthroscopically-assisted and image-intensifier-controlled double-button technique with an additional AC cerclage is a safe procedure that enables an anatomical reduction of the AC joint and yields good to excellent clinical results.

Management of chronic unstable acromioclavicular joint injuries

Abstract

The acromioclavicular joint represents the link between the clavicle and the scapula, which is responsible for the synchronized dynamic of the shoulder girdle. Chronic acromioclavicular joint instability involves changes in the orientation of the scapula, which provokes cinematic alterations that might result in chronic pain. Several surgical strategies for the management of patients with chronic and symptomatic acromioclavicular joint instability have been described. The range of possibilities includes anatomical and non-anatomical techniques, open and arthroscopy-assisted procedures, and biological and synthetic grafts. Surgical management of chronic acromioclavicular joint instability should involve the reconstruction of the torn ligaments because it is accepted that from three weeks after the injury, these structures may lack healing potential. Here, we provide a review of the literature regarding the management of chronic acromioclavicular joint instability.

Level of evidence

Expert opinion, Level V.

Arthroscopic Technique for Stabilization of Chronic Acromioclavicular Joint Instability With Coracoclavicular and Acromioclavicular Ligament Reconstruction Using a Gracilis Tendon Graft

We present an arthroscopic technique for stabilization of chronic acromioclavicular (AC) joint instability using a transclavicular-transcoracoidal button technique, combined with a coracoclavicular and AC ligament reconstruction using the gracilis tendon. This arthroscopic technique achieves an anatomic reduction of the clavicle without further implant removal. It ensures vertical and horizontal stabilization of the AC joint. Using a horizontal drill hole through the clavicle and looping the gracilis tendon graft around the coracoid avoids weakening of the coracoid with the risk of fracture.

[Injuries of the acromioclavicular joint: Hook plate versus arthroscopy]

Acute acromioclavicular (AC) joint injuries are common in clinical practice. The hook plate is a well-established conventional operative treatment option for high grade instability; however, arthroscopically-assisted flexible double button techniques are increasingly being used. Both procedures lead to good or excellent results. The advantages of the hook plate are the simple surgical technique and the possibility of an early functional aftercare. The minimally invasive one-step procedure with the possibility of identification and treatment of frequently concomitant glenohumeral pathologies is advantageous for the arthroscopic technique but mobilization is more restrictive. Available comparative studies have shown no significant clinical differences but a tendency towards better results with a higher degree of acceptance among patients for the arthroscopic and minimally invasive non-rigid double button procedures.

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.

Management of acute unstable acromioclavicular joint injuries

Surgical management of acute unstable acromioclavicular joint injuries should be focused on realigning the torn ends of the ligaments to allow for healing potential. The most widely utilized treatment methods incorporate the use of metal hardware, which can alter the biomechanics of the acromioclavicular joint. This leads to a second surgical procedure for hardware removal once the ligaments have healed. Patients with unstable acromioclavicular joint injuries managed with arthroscopy-assisted procedures have shown good and excellent clinical outcomes, without the need for a second operation. These procedures incorporate a coracoclavicular suspension device aimed to function as an internal brace, narrowing the coracoclavicular space thus allowing for healing of the torn coracoclavicular ligaments. The lesser morbidity of a minimally invasive approach and the possibility to diagnose and treat concomitant intraarticular injuries; no obligatory implant removal, and the possibility of having a straight visualization of the inferior aspect of the base of the coracoid (convenient when placing coracoclavicular fixation systems) are the main advantages of the arthroscopic approach over classic open procedures. This article consists on a narrative review of the literature in regard to the management of acute acromioclavicular joint instability.

Clinical Results After Conservative Management for Grade III Acromioclavicular Joint Injuries: Does Eventual Surgery Affect Overall Outcomes?

PURPOSE

To compare the clinical outcomes in patients with grade III acromioclavicular (AC) joint injuries in whom nonoperative therapy was successfully completed and those who had nonoperative therapy failure and who proceeded to undergo surgical reconstruction.

METHODS

Forty-nine patients were initially treated nonoperatively for grade III AC joint injuries with physical therapy. Patients completed questionnaires at initial presentation and after a follow-up period of 2 years. Outcome measures included the Short Form 12 Physical Component Score; American Shoulder and Elbow Surgeons score; Quick Disabilities of the Arm, Shoulder and Hand score; and Single Assessment Numeric Evaluation score. Failure of nonoperative treatment occurred when a patient underwent AC reconstruction before final follow-up.

RESULTS

Forty-one patients with a mean age of 39 years (range, 18 to 79 years) were included. In this cohort, 29 of 41 patients (71%) successfully completed nonoperative therapy whereas 12 of 41 (30%) had nonoperative therapy failure at a median of 42 days (range, 6 days to 17.0 months). Of the 41 patients, 39 (95.3%) were contacted to determine treatment success. Of the 12 patients who had nonoperative therapy failure, 11 (92%) had sought treatment more than 30 days after the injury. Subjective follow-up data were available for 10 of 12 patients (83.3%) who had nonoperative therapy failure and for 23 of 29 patients (79.3%) who were successfully treated nonoperatively. The mean length of follow-up was 3.3 years (range, 1.8 to 5.9 years). Although there were no statistically significant differences in outcome scores between groups, those who sought treatment more than 30 days after their injury showed decreased postoperative Single Assessment Numeric Evaluation scores (P = .002) and Short Form 12 Physical Component Scores (P = .037).

CONCLUSIONS

According to our results, (1) a trial of nonoperative treatment is warranted because successful outcomes can be expected even in patients who eventually opt for surgery and (2) patients who presented more than 30 days after their injury were less likely to complete nonoperative treatment successfully.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Arthroscopic treatment of acute acromioclavicular dislocations using a double button device: Clinical and MRI results

INTRODUCTION

Arthroscopic treatment of acute grade 3 and 4 acromioclavicular dislocation is controversial, due to the risk of recurrence and of postoperative reduction defect. The purpose of the present study was to investigate whether the healing of the acromioclavicular (AC) and coracoclavicular (CC) ligaments and the accurate 3D positioning parameters of the AC joint using MRI were correlated with satisfactory functional outcome.

MATERIAL

Thirty-nine patients were enrolled from 2009 to 2011 and managed arthroscopically by CC lacing using a double-button device.

METHODS

Clinical assessment included the Shoulder and Hand (QuickDash) score, Constant-Murley score and visual analog scale (VAS) for residual pain. Time and rate to return to work and return to sport were assessed according to type of sport and work. Postoperative complications were recorded. Radiological examination consisted of anteroposterior clavicle and lateral axillary radiographs. AC ligament healing and 3D joint congruency were assessed on MRI and correlated to the clinical results.

RESULTS

Mean patient age was 35.7 years (range, 20-55). Mean follow-up was 42.3±10.6 months (range, 24-60). At final follow-up, mean QuickDash score, Constant score and VAS were respectively 1.7±4 (range, 0-11), 94.7±7.3 (range, 82-100) and 0.5±1.4 (range, 0-2). Thirty-five (90%) patients were able to resume work, including heavy manual labor, and sport. Radiology found accurate 3D joint congruency in 34 patients (87%) and CC and AC ligament healing in 36 (93%). Complications included reduction loss at 6 weeks in 3 patients, requiring surgical stabilization. Satisfactory functional results were associated with accurate AC joint congruency in the coronal and axial planes (P<0.05) and good AC and CC ligament healing (P<0.04). An initial 25% reduction defect in the coronal plane was not associated with poor functional results (P=0.07).

CONCLUSION

Arthroscopic treatment by CC lacing satisfactorily restored ligament and joint anatomy in the present series. These satisfactory anatomic results correlated with good clinical outcome encourage continuing with this technique.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Multicenter Randomized Clinical Trial of Nonoperative Versus Operative Treatment of Acute Acromio-Clavicular Joint Dislocation

OBJECTIVE

To perform a randomized clinical trial of operative versus nonoperative treatment of acute acromio-clavicular (AC) joint dislocations using modern surgical fixation and both patient-based and surgeon-based outcome measures to determine which treatment method was superior.

DESIGN

Prospective, randomized.

SETTING

Multicenter.

PATIENTS/PARTICIPANTS

Eight-three patients with acute (<28 days from the time of injury) complete (grade III, IV, and V) dislocations of the AC joint.

INTERVENTION

Patients were randomized to operative repair with hook plate fixation versus nonoperative treatment (operative repair, 40; nonoperative treatment, 43).

MAIN OUTCOME MEASUREMENTS

Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year after injury. Assessment also included a complete clinical assessment, evaluation of the constant score, and a radiographic evaluation at 6 weeks, and at 3, 6, 12, and 24 months.

RESULTS

There were no demographic differences between the 2 groups, and the mechanisms of injury were similar between the 2 groups. The DASH scores (a disability score, lower score is better) were significantly better in the nonoperative group at 6 weeks (operative, 45; nonoperative, 31; P = 0.014) and 3 months (operative, 29; nonoperative, 16; P = 0.005). There were no significant differences between the groups at 6 months (operative, 14; nonoperative, 12; P = 0.442), 1 year (operative, 9; nonoperative, 9; P = 0.997), or 2 years (operative, 5; nonoperative, 6; P = 0.439) after injury. Constant scores were similar (better scores in the nonoperative group at 6 weeks, 3 months, and 6 months; P = 0.0001; and no difference thereafter). Although radiographic results were better in the operative group, the reoperation rate was significantly lower in the nonoperative group (P < 0.05).

CONCLUSIONS

Although hook plate fixation resulted in superior radiographic alignment, it was not clinically superior to nonoperative treatment of acute complete dislocations of the AC joint. The nonoperative group had better early scores, although both groups improved from a significant level of initial disability to a good or excellent result (mean DASH score, 5-6; mean constant score, 91-95) at 2 years. At present, there is no clear evidence that operative treatment with the currently available hook plate improves short-term outcome for complete AC joint dislocations.

Arthroscopically Assisted Anatomic Coracoclavicular Ligament Reconstruction Technique Using Coracoclavicular Fixation and Soft-Tissue Grafts

Acromioclavicular joint injuries are common and are often seen in contact athletes. Good to excellent clinical results have been reported using soft-tissue grafts to reconstruct the coracoclavicular ligaments; however, complications remain. Some complications are unique to the surgical technique, particularly clavicle and coracoid fractures that are associated with drilling large or multiple bone tunnels. The described technique allows for an anatomic coracoclavicular reconstruction using a large soft-tissue graft while minimizing the risk of clavicle fracture by avoiding large bone tunnels.

Two-Year Outcomes After Primary Anatomic Coracoclavicular Ligament Reconstruction

PURPOSE

The purpose of this study was to report the clinical and structural outcomes after anatomic coracoclavicular ligament reconstruction (ACCR) with free tendon allografts in patients with grade III and grade V acromioclavicular (AC) joint dislocations.

METHODS

Thirty-one shoulders underwent primary ACCR with tendon allografts for Rockwood grade III and grade V AC joint dislocations. Preoperative data included patient demographic characteristics, injury characteristics, and surgical history, along with American Shoulder and Elbow Surgeons (ASES) scores, Short Form 12 Physical Component Summary (SF-12 PCS) scores, and various pain scales. Outcome measures were also collected a minimum of 2 years postoperatively with the addition of Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; Single Assessment Numeric Evaluation (SANE) scores; and patient satisfaction. In addition, preoperative and postoperative coracoclavicular distances were analyzed using standard anteroposterior radiographs.

RESULTS

ACCR was performed in 31 patients (31 shoulders) with a mean age of 43.9 years (range, 21 to 71 years). In 7 patients (22.6%) a complication occurred that required a subsequent surgical procedure including graft rupture/attenuation (2), clavicle fractures (2), distal clavicle hypertrophy (2), and adhesive capsulitis (1). Of the remaining 24 patients, 20 (83.3%) had subjective outcome data available after a minimum 2-year follow-up period (mean, 3.5 years; range, 2.0 to 6.2 years). The mean postoperative ASES and SF-12 PCS scores significantly improved when compared with the preoperative baseline values (58.9 v 93.8 for ASES scores [P < .001] and 45.3 v 54.4 for SF-12 PCS scores [P = .007]). At final follow-up, the SANE and QuickDASH scores were 89.1 and 5.6, respectively, with a median patient satisfaction rating of 9 of 10.

CONCLUSIONS

Patients who did not require revision surgery showed excellent postoperative outcome scores: The mean ASES score was 93.8, the mean SANE score was 89.1, and the mean QuickDASH score was 5.6, with a median patient satisfaction rating of 9 of 10. Further study regarding ACCR techniques should focus on decreasing the risks of complications and maintaining reduction of the AC joint.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

[Injuries of the acromioclavicular joint in athletes]

Acromioclavicular joint (ACJ) dislocation is a common injury to the shoulder girdle, especially in contact and high velocity sports. Besides the severity of the injury, and particularly in competitive and elite athletes and the type of sports, individual career plans and in and out of season injuries have to be taken into account when advising treatment for athletes. Conservative treatment is reserved for low-grade dislocations and in-season athletes. The aim is fast pain relief and a safe return to competitive sport. High-grade ACJ dislocations in athletes should be treated surgically. Arthroscopic and arthroscopically-assisted techniques can offer a lower risk of infection, a higher patient acceptance in terms of cosmetic perspectives and the potential to treat concomitant glenohumeral lesions and may avoid potential disadvantages of open techniques, such as secondary obligatory implant removal and extensive soft tissue preparation with a relevant approach morbidity.

[Therapy of acute acromioclavicular joint instability. Meta-analysis of arthroscopic/minimally invasive versus open procedures]

BACKGROUND

A variety of surgical procedure are desrcibed for the treatment of acute acromioclavicular (AC-) joint injuries. Beside open techniques arthroscopic assisted procedures spread widely. Each surgical technique offers advantages and disadvantages, but none is currently accepted as a gold standard. Therefore, the study aims to review the evidence for arthroscopic and open surgical procedures in the treatment of acute AC joint instabilities.

MATERIAL AND METHODS

According to the Cochrane Handbook for Systematic Reviews of Interventions we conducted a defined search of Medline and Embase database for articles publisher over the last ten years.

RESULTS

The search resulted in 961 studies of which 32 were included in this review and 3 studies were suitable for a meta-analysis. The functional outcome (Constant score) showed a tendency towards better results after arthroscopic procedures (weighted mean difference 5.60, 95% confidence interval 0.36-10.64). There were no significant differences with respect to complication rates, secondary dislocation in the vertical plane, revision surgery and AC joint instability.

CONCLUSION

There is insufficient evidence to inform the surgical management of acute AC joint instability. Due to inconsistent study designs there is no evidence for a general superiority of any of the open or arthroscopic procedures. Randomized, controlled studies are necessary to demonstrate whether arthroscopic techniques show a potential benefit in terms of a better functional outcome.

Soft tissue injury of the shoulder after single non-dislocating trauma: prevalence and spectrum of intraoperative findings during shoulder arthroscopy and treatment results

BACKGROUND AND PURPOSE

The purpose of our study was to present the spectrum and prevalence of intraarticular lesions in patients with shoulder pain after a single non-dislocating shoulder trauma and to evaluate the clinical results according to pathology and workers' compensation status.

METHODS

Sixty consecutive patients (61 shoulders) with shoulder pain following a single non-dislocating shoulder trauma had shoulder arthroscopy. The indication for surgery was either persistent pain for 3 months or longer after trauma and/or an intraarticular lesion on MRI. Patients with history of shoulder complaints, previous shoulder surgery, a complete rotator cuff tear or a fracture of the shoulder girdle were excluded. Intraarticular findings during shoulder arthroscopy were retrospectively analyzed. After a minimum follow-up of 1 year patients were contacted by telephone interview and ASES score, Simple Shoulder Test, Subjective Shoulder Value and residual pain were assessed for the entire population and for patients with and without workers' compensation.

RESULTS

The most common intraarticular findings were SLAP (44.3 %) and Pulley (19.7 %) lesions followed by lesions of the anterior or posterior labrum (14.8 %). The mean age of the 13 women and 47 men was 41.9 years (SD 10.9). Patients with workers' compensation had significantly lower scores than patients without and had a significantly lower return to work rate than patients without.

INTERPRETATION

In patients with persistent shoulder pain after sprain or contusion arthroscopy revealed a broad spectrum of intraarticular findings. Patients with workers' compensation claims had worse results than those without.

LEVEL OF EVIDENCE

Case series (Level IV).

Anatomic reconstruction of chronic coracoclavicular ligament tears: arthroscopic-assisted approach with nonrigid mechanical fixation and graft augmentation

It has recently been suggested that all coracoclavicular ligament tears could be considered for surgery because nonoperative management might result in irreversible changes in the scapular position that could lead to muscle kinematic alterations that would perturb the shoulder girdle function and result in pain. In this technical note we describe an anatomic technique for the treatment of chronic coracoclavicular ligament tears that overcomes the issues related to open surgery, metal hardware, the inferior resistance to secondary displacement of only grafting and nonanatomic techniques, and the saw effect and anterior loop translation that can be seen in systems that surround the base of the coracoid. Our technique incorporates the use of a tendon graft and a nonrigid mechanical stabilizer that protects the graft from stretching during the process of healing and integration into bone, guaranteeing the maintenance of a reduced acromioclavicular joint.

Acromioclavicular joint dislocations

Acromioclavicular (AC) dislocation is a common injury especially among sportsmen. There is still a lack of consensus on whether to conserve or operate type III AC joint dislocations. Even among surgeons inclined to operate AC joint dislocations there is no unanimity on which surgical technique. There are a plethora of choices between mechanical fixation or synthetic materials or biologic anatomic reconstructions. Even among surgeons, there is a choice between open repairs and the latest-arthroscopic reconstructions. This review of AC joint dislocations intends to analyze the available surgical options, a critical analysis of existing literature, actual technique of anatomic repair, and also accompanying complications.

Associated lesions requiring additional surgical treatment in grade 3 acromioclavicular joint dislocations

PURPOSE

To evaluate the incidence of associated pathologic shoulder lesions that were addressed surgically in grade 3 acromioclavicular joint (ACJ) dislocations, as well as to compare this incidence between younger and older patients and between acute and chronic cases.

METHODS

In this multicenter nonrandomized retrospective study, 98 patients operated on for grade 3 ACJ dislocation underwent concomitant arthroscopic evaluation for the identification and treatment of any associated lesions. The type and treatment of associated lesions were collected in a central database and analyzed. We classified patients according to age (<45 years and ≥ 45 years) and according to the length of time between trauma and surgical treatment (≤ 30 days and ≥ 120 days), obtaining the following stratification: younger acute, older acute, younger chronic, and older chronic.

RESULTS

Of the patients, 42 (42.8%) were diagnosed with at least 1 additional pathologic lesion, and 29 (29.5%) required a dedicated additional treatment. Rates of treatment on associated lesions were analyzed: younger versus older groups presented a significant difference, as did younger acute versus older acute groups; SLAP and posterior rotator cuff tear treatments represented 24 of the 35 additional surgeries (68.5%).

CONCLUSIONS

The overall rate of associated pathologic lesions requiring additional surgical treatment in patients with ACJ dislocation was 29.5%. Patients aged 45 years or older had a greater risk of presenting with associated lesions that needed to be surgically addressed (odds ratio, 3.01). The overall rates of associated surgical lesions in acute versus chronic cases were not shown to be significantly different.

LEVEL OF EVIDENCE

Level IV, prognostic case series.