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

Both Arthroscopically Assisted Suture Button and Hook Plate Are Effective in Treating Acute High-grade Acromioclavicular Joint Dislocation: A Systematic Review

PURPOSE

To conduct a systematic review of clinical studies comparing the clinical outcomes of arthroscopically assisted suture button (AASB) and hook plate (HP) in the treatment of acute high-grade acromioclavicular joint (ACJ) dislocation to determine which technique provides superior clinical benefits.

METHODS

Two independent researchers conducted literature searches on the basis of Preferred Reporting Items from Systematic Reviews and Meta-analyses guidelines. PubMed, EMBASE, and the Cochrane Library were searched for studies that compared AASB and HP in treating acute high-grade (grade Ⅲ and greater) ACJ dislocation. Inclusion criteria included clinical studies that compared AASB and HP for acute Rockwood type III or greater dislocations with evaluations of functional outcomes (Constant score [CS], pain score, American Shoulder and Elbow Surgeons score, Disabilities of the Arm, Shoulder and Hand). Studies were excluded if they were case reports, reviews, or had missing data, revision procedures, or had loss to follow-up >20%. The methodologic quality of the included studies was assessed on the basis of Newcastle-Ottawa scale.

RESULTS

In this systematic review, 14 studies with 782 participants were included, all of which were classified as Level III-IV evidence. The analysis of 12 studies showed that the AASB group (81.9-95.31) had only slightly greater postoperative CS compared with the HP group (77.5-92.38), with 9 studies reporting significant improvements, whereas 3 studies found no significant difference compared with the HP group. For pain outcomes, 4 studies showed lower pain score in the AASB group, whereas the rest found no significant difference; the visual analog scale scores ranged from 0.3 to 3.61 in the AASB group and 0.5 to 4.9 in the HP group. Operation time was generally longer in the AASB group (AASB: 48.3-89.39 minutes; HP: 40.77-76.5 minutes). Complication rates were similar (AASB: 0%-50%; HP: 0%-36.36%), with only 1 study reporting a greater incidence in the AASB group. Minimal clinically important difference analysis from 3 studies showed clinically significant improvements in CS with AASB, but no significant difference between AASB and HP for pain outcomes.

CONCLUSIONS

AASB shows comparable outcomes to HP for acute high-grade ACJ dislocations, with similar ranges in clinical scores and complication rates. Although AASB shows some advantages in functional outcomes, the differences between the 2 methods are minimal, suggesting that both approaches are effective and safe.

LEVEL OF EVIDENCE

Level IV, systematic review of Level Ⅲ-IV studies.

Effect of Acromioclavicular Joint Injuries on the Acromioclavicular Joint Complex and Scapulohumeral Rhythm: A Functional and Mechanical Perspective

This overview approaches the acromioclavicular joint (ACJ) and ACJ injuries from a mechanical perspective that places the ACJ complex-the scapula, clavicle, ACJ, AC and coracoclavicular ligaments, and periscapular muscles-into the context of its ability to facilitate scapulohumeral rhythm (SHR) functions of scapula placement and humeral mobility. Mechanical concepts underlying this perspective include linkage of the scapula and clavicle into a single segment, the "claviscapula," the role of the AC and coracoclavicular ligaments in torque transduction and horizontal and vertical stability, and the deleterious effects of decoupling the claviscapular segment. The clinical examination and surgical treatment should address anatomic restoration of individual structures and the effect on the functional integrity of the entire ACJ complex within SHR. This context, which unifies anatomic injury with functional consequences, can be used to create a more comprehensive understanding of the clinical presentation and effect on ACJ function and SHR.

Arthroscopy-assisted procedure provides less residual horizontal instability and optimal coracoid tunnel creation with less radiation exposure compared to percutaneous procedure after endo-button fixation of type III AC joint dislocations

PURPOSE

The aim of this study was to evaluate the postoperative radiological and functional results of patients treated with arthroscopy-assisted (AA) and percutaneous (P) procedures using endo-button for type III acromioclavicular joint dislocations with a minimum 1-year follow-up. The study hypothesis was that the AA technique would provide more favourable coracoid tunnels.

METHODS

This retrospective study included patients who underwent surgery between 2017 and 2022. Computed tomography images taken immediately postoperatively of all the patients were analysed to group coracoid tunnels as optimal or suboptimal based on orientation and placement within the coracoid base. Residual horizontal instability was assessed using the bilateral Alexander view at the final follow-up. Shoulder functions were evaluated at the final follow-up examination.

RESULTS

Of the 63 patients, 39 underwent surgery using the percutaneous procedure and 24 with the AA procedure. Surgical duration was significantly longer in the AA group (AA: 61.1 ± 5.9 min; P: 34.7 ± 5.6 min) (p = 0.001; 95% confidence interval [CI]: 23.3-29.3), whereas fluoroscopy time was longer in the percutaneous group (AA: 2.0 ± 0.8 s; P: 15.7 ± 3.9 s) (p = 0.001; 95% CI: -14.9 to 12.3). Optimal coracoid tunnels were more frequently observed in the AA group (p = 0.001; 95% CI: 7.4-137.8). There was no significant difference in functional scores between the groups (n.s.). Postoperative horizontal instability was more common in the percutaneous procedure (p = 0.013; 95% CI: 8.3-39.2).

CONCLUSIONS

Although no difference was detected between the methods in terms of complications and functional results, the higher frequency of residual horizontal instability, the high risk of suboptimal tunnel creation and greater radiation exposure were seen to be the most important disadvantages of the percutaneous technique. During surgery, such technical problems related to the percutaneous method should be kept in mind and care should be taken about the orientation of the coracoid tunnel.

LEVEL OF EVIDENCE

Level III.

No Significant Difference Between Suture Button and Hook Plate in Treating Acute Rockwood Type III Acromioclavicular Joint Dislocation: A Systematic Review

PURPOSE

To systematically review the current evidence to compare the differences in outcomes of suture button (SB) versus hook plate (HP) fixation for treating acute Rockwood type III acromioclavicular joint (ACJ) dislocation.

METHODS

Two reviewers independently conducted a literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed, Embase, MEDLINE, and the Cochrane Library were systematically searched for studies comparing SB and HP in the treatment of acute Rockwood type III ACJ dislocation. Constant score, visual analog scale (VAS) score, coracoclavicular distance, operation time, and occurrence of complications were assessed. Risk of bias was assessed using The Cochrane Collaboration and Risk Of Bias In Non-randomized Studies-of Interventions tools.

RESULTS

A total of 16 studies were included, consisting of 2 randomized controlled trials and 14 non-randomized controlled trials, with 471 patients in the SB group and 445 patients in the HP group. Among the included studies that reported patient-reported outcomes, 4 indicated significantly higher Constant scores in the SB group compared with the HP group whereas the remaining 5 found no difference between the groups. Among the 5 included studies that reported VAS scores, 2 showed statistically significant differences favoring the SB group. Among the 10 included studies that reported operation time, 3 found a shorter operation time in the SB group than in the HP group whereas 2 indicated a longer operation time for SB surgery compared with HP treatment. However, there was no statistically significant difference in coracoclavicular distance or the incidence of complications between the 2 groups.

CONCLUSIONS

The evidence suggests no clear clinical superiority of SBs over HPs in treating acute Rockwood type III ACJ dislocations. Whereas some studies show that SB treatment may offer benefits such as higher Constant scores and lower VAS scores, most outcomes reveal no significant differences. LEVEL OF EVIDENCE: Level Ⅲ, systematic review of Level II and Ⅲ studies.

Return to Play After Surgical Treatment for Acromioclavicular Joint Dislocation: A Systematic Review

BACKGROUND

Acromioclavicular (AC) joint dislocation is a common clinical problem among young and athletic populations. Surgical management is widely used for high-grade dislocations (Rockwood III-VI) and in high-demand athletes at high risk of recurrence.

PURPOSE

To systematically review the evidence in the literature to ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after surgical treatment for AC joint dislocation.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted in the PubMed database. Clinical studies were eligible for inclusion if they reported on RTP after surgical treatment for AC joint dislocation. Statistical analysis was performed with SPSS.

RESULTS

We found 120 studies including 4327 cases meeting our inclusion criteria. The majority of patients were male (80.2%), with a mean age of 37.2 years (range, 15-85) and a mean follow-up of 34.5 months. Most were recreational athletes (79%), and the most common sport was cycling. The overall rate of RTP was 91.5%, with 85.6% returning to the same level of play. Among collision athletes, the rate of RTP was 97.3%, with 97.2% returning to the same level of play. In overhead athletes, the rate of RTP was 97.1%, with 79.2% returning to the same level of play. The mean time to RTP was 5.7 months (range, 1.5-15). Specific RTP criteria were reported in the majority of the studies (83.3%); time to return to play was the most commonly reported item (83.3%). Type III Rockwood injuries had the highest RTP rate at 98.7% and the earliest RTP at 4.9 months. Among the different surgical techniques, Kirschner wire fixation had the highest rate of RTP at 98.5%, while isolated graft reconstruction had the earliest RTP at 3.6 months.

CONCLUSION

The overall rate of RTP was reportedly high after surgical treatment for AC joint dislocation, with the majority of patients returning to their preinjury levels of sport. There is a lack of consensus in the literature for what constitutes a safe RTP, with further focus on this topic required in future studies.

Current Concepts in Management of Acromioclavicular Joint Injury

Background: The management of acromioclavicular joint injuries requires a thorough understanding of the anatomy and biomechanics of the joint, as well as knowledge of the pertinent physical exam findings and classification to determine an appropriate treatment approach, whether operative or nonoperative. In this article, we present a narrative review of the current state of understanding surrounding these issues. Although there are a large number of options for operative intervention, we additionally present our experience with anatomic coracoclavicular ligament reconstruction (ACCR) with imbrication of the deltoid fascia. Methods: A retrospective review of prospectively collected data on a total of 45 patients who had undergone ACCR between 2003 and 2016 were collected. Results: We found that improvements were seen in American Shoulder and Elbow Surgeons Score (ASES) (53 ± 19 to 81 ± 23), Simple Shoulder Test (SST) (6 ± 3 to 12 ± 13), Constant-Murley (CM) (60 ± 18 to 92 ± 8), and Rowe (67 ± 14 to 89 ± 11) and the mean post-operative SANE score was 86 ± 17. Conclusions: ACCR has the advantage of addressing both horizontal and vertical stability with good outcomes.