Is coracoclavicular stabilisation alone sufficient for the endoscopic treatment of severe acromioclavicular joint dislocation (Rockwood types III, IV, and V)?

Current trends in surgical treatment of the acromioclavicular joint injuries in 2023: a review of the literature

Background

This article examines the wide range of surgical reconstruction options available for acromioclavicular (AC) joint injuries. However, the lack of consensus regarding the most suitable surgical techniques is attributed to the high and variable failure rates observed with current approaches.

Methods

This article presents a comprehensive overview of the current surgical principles and techniques used by renowned experts in the field of AC shoulder injury management.

Results

It emphasizes the significance of addressing horizontal and rotational instability in AC injuries and highlights the impact of impaired scapular biomechanics.

Conclusion

By exploring these emerging concepts and strategies, the article aims to lay the foundation for future studies aimed at improving treatment outcomes and patient management.

Quality and stability of reduction of operated acromioclavicular dislocation using dual acromioclavicular and coracoclavicular stabilization

INTRODUCTION

Dual stabilization is advocated in acute acromioclavicular dislocation (ACD), but has been little assessed.

OBJECTIVE

This preliminary study performed clinical and radiological assessment of dual acromioclavicular (AC) and coracoclavicular (CC) stabilization in acute ACD. The study hypothesis was that dual stabilization allows satisfactory reduction that remains stable over time.

MATERIALS AND METHODS

A button was used under endoscopy for CC stabilization. For AC stabilization, a short approach was used; the joint was cleansed then stabilized by an anchored tape between the acromion and the clavicle to promote ligament healing. Clinical assessment was based on a visual analog pain scale (VAS), joint range of motion and Quick-DASH and Constant scores. Radiological reduction was assessed on the ratio of CC distance between the operated and healthy sides on two views. MRI was used in follow-up to screen for ligament healing: thickening and continuity.

RESULTS

Thirty-five patients with stage 3-5 acute dislocation were included. At a minimum 24 months' follow-up, mean clinical scores were very satisfactory, with recovery of motion and pain relief. Radiography showed 94% stable reduction in both vertical and horizontal planes. MRI confirmed CC and AC ligament healing. Postoperative complications mainly comprised 4 cases of reduction loss (11%). One clavicle fracture occurred, at 6 months.

CONCLUSION

Dual AC-CC stabilization provided very good radiographic reduction in both horizontal and vertical planes. Functional results were very satisfactory, and complications were few, with some cases of reduction loss. These good results encourage us to continue with dual stabilization in acute ACD.

LEVEL OF EVIDENCE

II; prospective cohort.

High Vertical and Horizontal Stability at Short-Term Follow-Up After an All-Endoscopic Double Cerclage Endobutton Technique for Acute Acromioclavicular Joint Separations

PURPOSE

To evaluate the clinical and radiological outcomes in the treatment of acute acromioclavicular (AC) joint separations using an all-endoscopic double cerclage endobutton technique compared with an arthroscopic-assisted single-bundle endobutton technique and to analyze the complication, failure, and revision rates of both procedures.

METHODS

All patients with acute Rockwood type IIIB and V AC joint separations who were operated on using an all-endoscopic double cerclage technique (2019-2022) or an arthroscopic-assisted single-bundle technique (2017-2019) were included. The follow-up period was at least 12 months. Clinical and radiographic assessment was performed at follow-up. Complications, failures, and revisions were also investigated.

RESULTS

Twenty-eight patients (14 double cerclage group, 14 single-bundle group, all male) with an average age of 37 years (interquartile range [IQR], 15) were available for follow-up after 45 months (IQR, 38). The median time between trauma and surgery was 7 days (IQR, 8). Very good clinical results without significant differences were observed in both groups (Constant score, 94 [IQR, 12] vs 95 [IQR, 15], P = .427, AC joint instability score, 95 [IQR, 11] vs 87 [IQR, 22], P = .210). All patients returned to sport, with an average sports level of 95% compared with preoperative status. The single-bundle group showed significantly increased anteroposterior instability (6 vs 0, P = .006). A total of 5 complications occurred (2 vs 3), leading to 1 revision surgery in each group.

CONCLUSIONS

Excellent clinical results and high vertical and horizontal stability can be achieved with the all-endoscopic double cerclage technique. Horizontal instability occurred significantly more frequently with the single-bundle technique. The prolonged operation time in the double cerclage group had no negative impact on postoperative outcomes, including complication and failure rates, and a learning curve to reduce this prolonged operative time should be considered.

LEVEL OF EVIDENCE

Level III, retrospective comparative clinical series.

Mid-term clinical and sonographic outcomes of minimally invasive acromioclavicular joint reconstruction: mini-open versus arthroscopically assisted

INTRODUCTION

The current literature describes various operative stabilization strategies which achieve good clinical outcomes after acute acromioclavicular joint (ACJ) dislocation. The aim of this study was to compare the mid-term clinical and sonographic treatment outcomes after minimally invasive mini-open and arthroscopic reconstruction.

MATERIALS AND METHODS

We conducted a retrospective two-center study of patients with acute ACJ dislocation. Surgical treatment was performed using either a mini-open approach (MIOP) or an arthroscopic technique (AR). The primary outcome parameters of this study were the sonographically measured acromioclavicular (ACD) and coracoclavicular distances (CCD). Secondary outcome parameters included the Constant-Murley score (CS), range of motion (ROM), postoperative pain scale (VAS), return to daily routine, return to sports, complications, as well as operative revisions.

RESULTS

After a mean follow-up of 29 months, 30 patients were included in this study with an average age of 41.3 ± 14.8 years (MIOP) and 41.2 ± 15.4 years (AR). The sonographic ACD (MIOP 9.11 mm vs. AR 8.93 mm, p = 0.41) and CCD (MIOP 25.08 mm vs. AR 24.36 mm, p = 0.29) distances showed no statistically significant differences. Furthermore, there was no statistically significant difference when compared to the contralateral side (p = 0.42). With both techniques, patients achieved excellent clinical outcome parameters without statistically significant differences in CS (MIOP 95 vs. AR 97, p = 0.11) and VAS (MIOP 1.76 vs. AR 1.14, p = 0.18). The return to daily activity and return to sport rates did not differ. There were neither complications nor revisions in both groups.

CONCLUSION

Both minimally invasive techniques for acute ACJ stabilization achieved excellent clinical and sonographic outcomes without one technique being statistically superior to the other.

The importance of a structured failure analysis in revision acromioclavicular joint surgery: A multi-rater agreement on the causes of stabilization failure from the ISAKOS shoulder committee

BACKGROUND

Acromioclavicular joint (ACJ) stabilizations are associated with a high overall failure rate with 9.5% of these patients requiring subsequent revision surgery. Consequently, understanding the specific cause of primary ACJ stabilization failure is paramount to improving surgical decision-making in this challenging patient cohort.

PURPOSE

To (1) identify risk factors and mechanisms for failure following primary arthroscopically-assisted ACJ stabilization to highlight the importance of conducting a detailed failure analysis and to (2) establish revision strategies based on real-life cases of primary failed ACJ stabilization.

STUDY DESIGN

Level of evidence IV.

METHODS

A survey was shared internationally among members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) shoulder committee. The survey contained failure analysis of 11 real-life cases of failed primary arthroscopically-assisted ACJ stabilization. For each case, a thorough patient history, standardized radiographs, and CT scans were provided. Participants were asked to give their opinion on bone tunnel placement, cause of failure (biological, technical, traumatic, or combined), the stabilization technique used, as well as give a recommendation for revision.

RESULTS

Seventeen members of the ISAKOS shoulder committee completed the survey. Biological failure was considered the most common cause of failure (47.1%), followed by technical (35.3%) and traumatic (17.6%) failure. The majority deemed two modifiable factors (i.e., patient's profession and sport) as well as non-modifiable factors (i.e., patient's age and time from trauma to initial surgery) to be risk factors for failure. In 10 of 11 cases, the correct fixation device was used in the primary setting (90.9%; 52.8-82.4% agreement); however, in eight of those cases, the technique was not performed correctly (80.0%; 58.8-100% agreement). In 8 of all 11 cases, the majority recommended an arthroscopically assisted technique with graft augmentation for revision (52.9-58.8% agreement).

CONCLUSION

Biological failure and technical failure are the most common reason for failure in primary ACJ stabilization followed by traumatic failure. Besides, biological failure can be triggered by technical errors such as clavicular or coracoidal tunnel misplacement. Consequently, a detailed failure analysis including preoperative CT should be conducted on the causes of primary ACJ failure, and, if possible, an arthroscopically-assisted technique with graft augmentation should be prioritized in revision ACJ surgery.

CLINICAL RELEVANCE

ACJ stabilizations are associated with a high overall failure rate - potentially due to biological and technical properties. When encountering failed arthroscopically-assisted ACJ stabilization, a detailed failure analysis should be conducted on the causes of primary ACJ failure. Furthermore, an arthroscopically-assisted revision stabilization is feasible in most cases.

Bibliometric and visualized analysis of arthroscopic treatment of acromioclavicular joint injury

BACKGROUND

Since arthroscopy was discovered to treat acromioclavicular joint injury, people have had great interest and attention to this beautiful and minimally invasive operation, and related research has been increasing worldwide. At present, there is no bibliometric and visualized analysis in this field. The purpose of this study is to explore the research hotspots and trends of arthroscopic treatment of acromioclavicular joint injury through bibliometric and visualized analysis and look forward to the future development direction of clinical practice.

METHODS

The publications on arthroscopic treatment of acromioclavicular joint injury diseases from its establishment to April 2023 were obtained from the Web of Science (WOS) Core Collection database. CiteSpace, VOSviewer, Scimago graphica and Origin were used for bibliometric and visualized analysis.

RESULTS

This study included a total of 330 publications. The number of publications tends to increase every year. The USA has the most significant number of publications and citations. Imhoff AB is the most relevant scholar with the largest number of publications in this field, and the scholar with the highest citation and average citations is Mazzocca AD. Tech Univ Munich, Rush University and Charite are the three institutions with the greatest contribution. Tech Univ Munich, Rush University and Charite are the three institutions with the greatest contribution. In addition, "Arthroscopy-the Journal of Arthroscopic and Related Surgery" and "American Journal of Sports Medicine" are the institutions with the most significant number of publications and average citations, respectively. The most common keywords are "acromioclavicular joint dislocation," "arthroscopic resection," "arthroscopic reconstruction" and "coracoclavicular ligament."

CONCLUSION

The number of publications shows a steady upward trend as a whole. However, there is still a lack of cooperation among countries, institutions and scholars around the world, so various countries, institutions and scholars need to strengthen academic exchanges and expand the field of cooperation, so as to promote further research and development in related fields. However, minimally invasive methods such as arthroscopy are still the hotspots and frontiers in the treatment of acromioclavicular joint injury in the future.

Prospective Multicenter Randomized Controlled Trial of Surgical Versus Nonsurgical Treatment for Acute Rockwood Type 3 Acromioclavicular Injury

Background

Evidence for the superiority of surgical versus nonsurgical treatment of Rockwood type 3 acromioclavicular joint (ACJ) dislocation is still lacking.

Hypothesis

It was hypothesized that surgical treatment will outperform nonsurgical treatment.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

A prospective randomized trial involving 4 study centers was performed from January 1, 2011, to March 31, 2016. A total of 85 patients with acute Rockwood type 3 ACJ dislocations were allocated randomly to receive either nonsurgical or surgical treatment. A total of 70 patients were treated as allocated, and 8 patients made an early crossover from nonsurgical to surgical treatment, leaving 47 patients treated surgically and 31 patients nonsurgically. All patients were followed up longitudinally, including clinical evaluation using the Constant score and standardized radiographic evaluation, with final follow-up after 2 years.

Results

At no follow-up time point was there a significant difference in Constant score between the surgically and nonsurgically treated patients. Radiographic analysis showed not only an inferior coracoclavicular distance at all follow-up points for surgical treatment but also a higher incidence of posttraumatic osteoarthritis and heterotopic ossifications, without any negative clinical correlation. With regard to complications, 1 patient (3%) in the nonsurgical group underwent secondary surgical ACJ stabilization. The revision rate after surgical treatment was 17% (P < .001). Neither primary horizontal instability nor younger age were associated with inferior clinical outcomes after nonsurgical treatment.

Conclusion

Surgical treatment of ACJ Rockwood type 3 injuries did not lead to superior functional outcomes. Neither younger age nor horizontal instability were associated with inferior outcomes after nonsurgical treatment. Surgical treatment led to a slower recovery and to higher complication and revision rates.

Registration

ISRCTN registry (study ID: ISRCTN92265154).

Current concepts in acromioclavicular joint (AC) instability - a proposed treatment algorithm for acute and chronic AC-joint surgery

BACKGROUND

There exists a vast number of surgical treatment options for acromioclavicular (AC) joint injuries, and the current literature has yet to determine an equivocally superior treatment. AC joint repair has a long history and dates back to the beginning of the twentieth century.

MAIN BODY

Since then, over 150 different techniques have been described, covering open and closed techniques. Low grade injuries such as Type I-II according to the modified Rockwood classification should be treated conservatively, while high-grade injuries (types IV-VI) may be indicated for operative treatment. However, controversy exists if operative treatment is superior to nonoperative treatment, especially in grade III injuries, as functional impairment due to scapular dyskinesia or chronic pain remains concerning following non-operative treatment. Patients with a stable AC joint without overriding of the clavicle and without significant scapular dysfunction (Type IIIA) may benefit from non-interventional approaches, in contrast to patients with overriding of the clavicle and therapy-resistant scapular dysfunction (Type IIIB). If these patients are considered non-responders to a conservative approach, an anatomic AC joint reconstruction using a hybrid technique should be considered. In chronic AC joint injuries, surgery is indicated after failed nonoperative treatment of 3 to 6 months. Anatomic AC joint reconstruction techniques along with biologic augmentation (e.g. Hybrid techniques, suture fixation) should be considered for chronic high-grade instabilities, accounting for the lack of intrinsic healing and scar-forming potential of the ligamentous tissue in the chronic setting. However, complication and clinical failure rates remain high, which may be a result of technical failures or persistent horizontal and rotational instability.

CONCLUSION

Future research should focus on addressing horizontal and rotational instability, to restore native physiological and biomechanical properties of the AC joint.

Does the choice of the optic portal influence the radiographic and early functional results in acute acromioclavicular disjunctions?

Exposure of the coracoid process during arthroscopic stabilization of acute acromioclavicular disjunctions (ACDs) can be achieved either by passing an extra- articular optical portal through the subacromial space or by an intra-articular optical route through the glenohumeral joint with opening of the rotator interval. The objective of our study was to compare the impact on the functional results of these two optical routes. This was a retrospective, multicentre study that included patients operated on for an acute acromioclavicular disjunction arthroscopically. The treatment consisted of surgical stabilization under arthroscopy. The surgical indication was retained for an acromioclavicular disjunction of grade 3, 4 or 5, according to the Rockwood classification. Group 1, which consisted of 10 patients, was operated on with an extra-articular subacromial optical route, and group 2, which consisted of 12 patients, was operated on with an intra-articular optical route with opening of the rotator interval according to the habits of the surgeon. A follow-up of 3 months was performed. The functional results were evaluated for each patient using the Constant score, Quick DASH, and SSV. The delays in returning to professional and sports activities were also noted. A precise postoperative radiological analysis made it possible to analyse the quality of the radiological reduction. No significant difference between the two groups was found between the Constant score (88 vs. 90; p = 0.56), Quick DASH (7 vs. 7; p = 0.58), or SSV (88 vs. 93; p = 0.36). The times to return to work (6.8 weeks vs. 7.0 weeks; p = 0.54) and sports activities (15.6 weeks vs. 19.5 weeks; p = 0.53) were also comparable. The quality of the radiological reduction was satisfactory in the two groups and did not depend on the approach. No clinically or radiologically significant differences between the extra-articular and intra-articular optical portals in the surgical treatment of acute ACDs were found. The optical route can be chosen according to the habits of the surgeon.

Clinical and anatomical outcomes of isolated coracoclavicular fixation after acromioclavicular joint injury: is it stable enough or is additional horizontal fixation necessary?

Background

Recently, an emphasis has been put on anatomical reduction of acromioclavicular (AC) joint both in vertical and hortizontal planes for management of AC joint injuries due to persisting horizontal instability. Therefore, an additional AC fixation in horizontal plane has been recommended. However, relation between horizontal AC joint instability and clinical outcomes is still controversial. This study aims to evaluate outcomes of isolated coraco-clavicular fixation using arthroscopic assisted single coraco-clavicular tunnel technique in grade III and V AC joint injuries and to investigate the correlation between anatomical and clinical outcomes.

Methods

This study was conducted with 19 patients with grade III or V AC joint injury. Clinical outcomes included postoperative pain intensity and functional outcomes (Constant Score, American Shoulder and Elbow Surgeons, and Subjective Shoulder Value). Radiological evaluations were performed using radiographs and postoperative computed tomography scans. Degree of initial injury and postoperative stability both on axial and coronal planes were evaluated after radiological assessment. Correlations between anatomical and clinical outcomes were investigated using Pearson's correlation test.

Results

At the final follow-up assessment, the mean pain score was 1.8 ± 1.8, mean American Shoulder and Elbow Surgeons score was 81.0 ± 15.4, mean Subjective Shoulder Value was 81.3 ± 19.6, and mean Constant Score was 86.3 ± 14.8. The mean loosening ratio and AC distance were 43.5 ± 30.6% and 4.3 ± 12.4 mm, respectively. No correlation was observed between postoperative anatomical and clinical outcomes (P > .05).

Conclusion

Additional AC fixation on horizontal plane is not a prerequisite for all injuries, there is no significant association between horizontal instability and clinical outcomes and indications of an additional AC fixation needs to be determined.

Arthroscopic Treatment of Chronic Acromioclavicular Dislocation With Semitendinosus Autograft and Coracoclavicular Suspension Fixation

The management of acromioclavicular dislocations remains controversial. On many occasions, these chronic dislocations are asymptomatic. However, there are patients who, despite good rehabilitation treatment, do present with pain, periscapular muscle fatigue, weakness, paresthesia or scapular dyskinesia. In these patients, surgical treatment is indicated.

Surgical treatments for acute unstable acromioclavicular joint dislocations

INTRODUCTION

Surgical treatment is usually recommended for acute, high-grade acromioclavicular joint (ACJ) injuries. A wide variety of surgical techniques exist, and the literature does not strongly support one over the other. In this literature review, we describe and compare the results of different surgical treatments for the management of acute unstable ACJ dislocation and aim to guide surgeons on optimal treatment.

MATERIALS AND METHODS

A literature review was performed by searching PubMed, Medline, Cochrane, and Embase databases. Seventeen studies met the inclusion criteria and were analyzed. Only studies with comparative data were included. The clinical and radiological outcomes of these studies were reviewed.

RESULTS

Seventeen studies were included in this literature review. We found no difference in outcomes between open and arthroscopic procedures. Coracoclavicular ligament (CCL) reconstruction techniques provide better results than the more rigid hook plate fixation. There is no evidence that biologic repair with tendon graft is superior to synthetic grafts. Furthermore, an autograft is not shown to be better than an allograft. Rigid fixation between the clavicle and coracoid and the non-anatomic Weaver-Dunn technique appears less popular in recent literature. The hook plate is associated with subacromial osteolysis, acromial erosion, and the morbidity of a secondary procedure.

DISCUSSION

There is a recent increase in publications on the reconstruction of the ACJ after injury, with new techniques focusing on the anatomic reconstruction of the CCLs aiming to restore both vertical and horizontal plane stability of the ACJ using synthetic/biological grafts. Despite the plethora of new techniques introduced, meaningful comparisons are difficult to draw due to the heterogeneity of the treatments used and the outcome measure used to assess the results.

High Early-onset acromioclavicular secondary pathologies after acute arthroscopic joint reduction: a cohort study

PURPOSE

The research aim was to determine the prevalence and risk factors of early secondary acromioclavicular (AC) joint disease in patients undergoing acute arthroscopic AC joint reduction and fixation and early complications of acute surgical treatment in patients with high-grade AC joint dislocation.

METHODS

Overall, 102 patients diagnosed with Rockwood type V AC joint dislocation and undergoing arthroscopic coracoclavicular fixation were included. Early clinical and radiological complications were evaluated, as well as risk factors of secondary AC joint pathology.

RESULTS

Twenty-nine patients (28%) presented with a secondary AC joint pathology, with 24 and 5 cases of osteolysis and osteoarthritis, respectively. The main complication was a loss of reduction of ≥ 1 mm (78%). Patients aged > 55 years were more likely to develop a secondary AC joint disease (odds ratios (OR) = 10.1, 95% confidence interval (CI): 1.42 - 72.55, p = 0.021). Patients with osteolysis (OR = 3.2, 95% CI 1.16 - 9.27, p = 0.025) or loss of reduction of > 5 mm (OR = 7.4, 95% CI 2.31 - 24.08, p = 0.001) were more likely to develop AC joint pain. Patients with an initial over-reduction were less likely to develop a subluxated AC joint (OR = 0.033, 95% CI 0.0021-0.134, p = 0.001) CONCLUSION: Age > 55 years and female sex were identified as risk factors of early-onset secondary AC joint disease. Osteolysis and a loss of reduction of > 5 mm were risk factors of AC joint pain but not of revision surgery. The main early complication was a loss of reduction of ≥ 1 mm. An initial over-reduction of the distal clavicle was a protective factor to avoid AC joint subluxation.

The Morphology of the Acromioclavicular Joint Does Not Influence the Postoperative Outcome Following Acute Stabilization—A Case Series of 81 Patients

Purpose

To specifically evaluate the influence of the acromioclavicular (AC)-joint morphology on the outcome after arthroscopically assisted coracoclavicular (CC) stabilization surgery with suspensory fixation systems and to investigate whether an additional open AC-joint reduction and AC cerclage improves the clinical outcome for patients with certain morphologic AC-joint subtypes.

Methods

Patients with an acute acromioclavicular joint injury, who underwent arthroscopically assisted CC stabilization with suspensory fixation systems with or without concomitant AC cerclage between January 2009 and June 2017 were identified and included in this retrospective cohort analysis. AC-joint morphology was assessed on preoperative radiographs and categorized as “flat” or “non-flat” (“oblique”/“curved”) subtypes. After a minimum of 2 years of follow-up, postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES), and visual analog scale (VAS) scores for pain were collected. A subgroup analysis of clinical outcomes depending on the surgical technique and morphological subtype of the AC joint was performed.

Results

Eighty-one patients (95% male, mean age 35 ± 12 years) could be included at a mean follow-up of 57 ± 14 months. Radiographic assessment of AC-joint morphology showed 24 (30%) cases of flat type, 38 (47%) cases of curved type, and 19 (23%) cases of oblique morphology. Postoperatively, no clinically significant difference could be detected after the treatment of AC joint injury via CC stabilization with or without concomitant AC cerclage (VAS_rest: P = .067; VAS_max: P = .144, ASES: P = .548; SANE: P = .045). No clinically significant differences were found between the surgical techniques for the flat morphologic subtype (VAS_rest: P = .820; VAS_max: P = .251; SANE: P = .104; ASES: P = .343) or the non-flat subtype (VAS_res: P = .021; VAS_max: P = .488; SANE: P = .243, ASES: P = .843).

Conclusions

In arthroscopically assisted AC stabilization surgery with suspensory fixation systems for acute AC-joint injury, the AC-joint morphology did not influence the postoperative outcome, independent of the surgical technique. No clinical benefit of performing an additional horizontal stabilization could be detected in our collective at mid-term follow-up.

Level of Evidence

Level IV, therapeutic case series.

There is direct relationship between bone bridge length and coracoclavicular fixation resistance to failure: Biomechanical study in a porcine model

BACKGROUND

This study aims to evaluate the relation between coracoclavicular resistance to failure and the distance between clavicular tunnels. The hypothesis is that a greater clavicular bone bridge between tunnels achieves a stronger coracoclavicular fixation.

METHODS

Descriptive Laboratory Study. Thirty-six (36) coracoclavicular models were constructed utilizing porcine metatarsals. Coracoclavicular stabilizations were performed using a subcoracoid loop fixation configuration through two clavicular tunnels, tied at the clavicle's superior cortex using a locking knot. Models were randomly assigned to 1 of 3 experimental groups of variable bone bridge length between clavicular tunnels: 5 mm, 10 mm, and 15 mm. Each group had 12 models. Fixation resistance was assessed through the ultimate failure point under an axial load to failure trial. Failure patterns were documented. A one-way ANOVA test was used, and a Tukey post hoc as needed (P < 0.05).

FINDINGS

Mean strength per bone bridge length: 5 mm = 312 N (Range: 182-442 N); 10 mm = 430 N (Range: 368-595 N); 15 mm = 595 N (Range: 441-978 N). The 15 mm group had a significantly higher ultimate failure point than the other two groups: 5 mm (P < 0.001) and 10 mm (P < 0.001). All fixations systematically failed by a superior cortex clavicle fracture at the midpoint between tunnels.

INTERPRETATION

A direct relationship between bone bridge length and coracoclavicular resistance to failure was demonstrated, being the 15 mm length a significantly higher strength construct in a tied loop model.

Arthroscopy-Assisted All-Suture Coracoclavicular and Acromioclavicular Joint Stabilization in Acute Acromioclavicular Joint Injuries

The existing literature agrees on surgical management for Rockwood grade IV and V injuries, but there is no consensus which type of surgery is the most appropriate one. More than 150 surgeries have been described for this condition in the literature. In an injury of less than 3 weeks, most surgeons prefer suture-button devices for coracoclavicular stabilization. Recent biomechanical studies have demonstrated that coracoclavicular stabilization provides good vertical stability but poor horizontal stability of acromioclavicular joint. Hence, they recommend acromioclavicular stabilization along with coracoclavicular stabilization. The use of a suture-button device for coracoclavicular stabilization requires special implants and instruments along with high surgical skills to drill precisely placed holes in the clavicle and the coracoid in order to avoid fractures from the drill hole. Due to relatively smaller clavicle and coracoid in Asian population, making holes in the clavicle and the coracoid has increased risk of fracture. We describe a technique in which no drill holes are made in the clavicle or the coracoid. In our technique, suture tape is used, which is looped around the coracoid and the clavicle, and the limbs are tied over the clavicle to maintain the coracoclavicular distance. The remaining limbs of suture tape is further looped through the tunnels made in acromion and tied over the acromion to augment the acromioclavicular ligament. The potential advantages of this technique are no costly implant and instruments are required, avoidance of complications associated with drill holes in coracoid and clavicle, both coracoclavicular and acromioclavicular joints are stabilized, direct repair of the acromioclavicular ligament can be performed, and no need of second surgery for implant removal.

Functional and Radiographic Outcomes of Intraoperatively Decreasing the Coracoclavicular Distance to 50% of the Unaffected Side in Stabilization of Acute Acromioclavicular Joint Injury: A Retrospective Evaluation

Background:

The postoperative failure rate of acromioclavicular (AC) joint fixation using the coracoclavicular (CC) stabilization technique is high. Studies have reported that compared with normal intraoperative anatomic reduction, intraoperative overreduction of the AC joint is more successful in achieving a satisfactory anatomic radiographic outcome at 1- to 2-year follow-up.

Purpose:

To evaluate the functional and radiographic outcomes and complications in patients with acute AC joint injury who underwent combined CC stabilization and AC capsular repair in which the CC distance was intraoperatively decreased to 50% of the unaffected side.

Study Design:

Case series; Level of evidence, 4.

Methods:

In this retrospective study, we collected and analyzed the data of patients with an acute AC joint injury (Rockwood type 5) who underwent combined CC stabilization and AC capsular repair during which the CC distance was decreased 50% compared with the unaffected side. At 2-year follow-up, we evaluated functional outcomes (American Shoulder and Elbow Surgeons [ASES] score), radiographic outcomes (alignment of the AC joint in the vertical and horizontal planes, tunnel widening), and complications (infection, clavicular fracture).

Results:

The study included 20 patients with a mean ± SD age of 42.20 ± 10.10 years. The mean follow-up period was 33.75 ± 11.50 months. At the 2-year follow-up, the mean ASES score was 95.13 ± 5.61. The overreduction alignment, anatomic alignment, and loss reduction alignment rates were 0% (0/20 patients), 95% (19/20 patients), and 5% (1/ 20 patients), respectively. No statistically significant difference was found in the mean CC distance between the affected and unaffected sides on radiographic evaluation. The mean medial clavicular tunnel width and lateral clavicular tunnel width were 5.03 ± 0.68 mm and 4.47 ± 0.67 mm, respectively. None of the patients experienced fractures or infections.

Conclusion:

Excellent functional and radiographic outcomes and no complications were seen at 2-year follow-up in patients with acute AC joint injury who underwent combined CC stabilization and AC capsular repair with the CC distance intraoperatively decreased to 50% of the unaffected side.

Early and delayed acromioclavicular joint reconstruction provide equivalent outcomes

BACKGROUND

Some comparative studies have reported improved outcomes for early compared with delayed reconstruction for high-grade acromioclavicular (AC) joint dislocations. However, most are based on older techniques and did not specifically involve reconstruction of both the coracoclavicular (CC) and AC joint ligaments. The purpose of this study was to compare functional outcomes of early vs. delayed surgical intervention of AC joint dislocations managed with combined CC and AC ligament reconstruction.

METHODS

A retrospective comparative study was performed of 53 patients who underwent early (<2 weeks after injury) or delayed (≥2 weeks after injury) open stabilization for AC joint dislocation. All patients were managed with the same surgical technique of combined CC reconstruction and stabilization of the AC joint, except for the addition of a gracilis allograft for biologic CC reconstruction in delayed intervention. Outcome was determined at a minimum follow-up of 12 months, using the Acromioclavicular Joint Instability (ACJI) score, Taft score, Subjective Shoulder Value (SSV), visual analog scale (VAS) for pain, and overall satisfaction (0-10). Multivariable regression analyses were performed to test associations of ACJI and Taft scores with 5 independent variables (early vs. delayed surgery, age, sex, manual worker, and Rockwood type).

RESULTS

The cohort comprised 47 men (89%) and 6 women (11%) aged 40.1 ± 11.2 years (range, 22-63 years). The early group (n = 31) underwent surgery 1.1 ± 0.5 weeks after injury, whereas the delayed group (n = 22) underwent surgery 84.3 ± 99.1 weeks after injury. There were no significant differences in ACJI scores (87 ± 14 vs. 89 ± 14, P = .267), Taft scores (10.1 ± 1.3 vs. 10.7 ± 1.3, P = .084), pain on VAS (0.3 ± 0.7 vs. 0.6 ± 1.1, P = .541), SSV (95 ± 7 vs. 93 ± 9, P = .427), or overall satisfaction (9.6 ± 0.9 vs. 9.4 ± 1.1, P = .491). Multivariable analyses revealed no associations between any of the independent variables and ACJI or Taft score.

CONCLUSIONS

Early and delayed surgical interventions of high-grade AC joint dislocation provide equivalent clinical scores when combined CC and AC joint fixation is used for stabilization. Rapid surgical intervention for high-grade AC joint dislocation may not be necessary, as most patients can still benefit from surgery at a later stage.

All-Endoscopic Treatment of Acromioclavicular Joint Dislocation: Coracoclavicular Ligament Suture and Acromioclavicular Ligament Desincarceration

Acute acromioclavicular (AC) joint dislocations are common and difficult to manage. The physiopathologic pattern begins with the rupture of the AC ligaments, then the coracoclavicular (CC) ligaments, and with an invasion of the clavicle through the deltotrapezial fascia. Therefore, we tend to perform a true suture of the CC ligaments, along with a release of the AC ligaments from the joint. We thus propose an all-endoscopic CC ligament suture and AC joint release. It starts with glenohumeral exploration enabling a repair of concomitant lesions when necessary. Dissection of the coracoid process is made, along with the lateral border of the conjoint tendon, medially the pectoralis minor tenotomy, and plexus brachial exposition and protection. Superiorly the CC ligaments are tagged and exposed. A major difference with others procedure then arises. We dissect the inferior and superior surfaces of the clavicle and the AC joint, although we maintain the continuity between the deltotrapezoid fascia and the AC ligaments. The AC dislocation is reduced under endoscopic control performing a true suture of the CC ligaments by the mean of 2 suture tapes and dog bones. After surgery, a shoulder brace is used for 6 weeks. Physiotherapy then begins.

The acromioclavicular ligament shows an early and dynamic healing response following acute traumatic rupture

Purpose

Symptomatic horizontal instability is clinically relevant following acute acromioclavicular joint dislocations. However, the intrinsic healing response is poorly understood. The present study sought to investigate time-dependent healing responses of the human acromioclavicular ligament following acute traumatic rupture.

Methods

Biopsies of the acromioclavicular ligament were obtained from patients undergoing surgical treatment for acute acromioclavicular joint dislocations. Specimens were stratified by time between trauma and surgery: group 1, 0–7 days (n = 5); group 2, 8–14 days (n = 6); and group 3, 15–21 days (n = 4). Time-dependent changes in cellularity, collagen (type 1 and 3) concentration, and histomorphological appearance were evaluated for the rupture and intact zone of the acromioclavicular ligament.

Results

Group 1 was characterized by cellular activation and early inflammatory response. The rupture zone exhibited a significantly higher count of CD68-positive cells than the intact zone (15.2 vs 7.4; P ≤ 0.05). Consistently, synovialization of the rupture end was observed. Within the second week, the rupture zone was subject to proliferation showing more fibroblast-like cells than the intact zone (66.8 vs 43.8; P ≤ 0.05) and a peak of collagen type 3 expression (group 1: 2.2 ± 0.38, group 2: 3.2 ± 0.18, group 3: 2.8 ± 0.57; P ≤ 0.05). Signs of consolidation and early remodeling were seen in the third week.

Conclusions

The acromioclavicular ligament exhibits early and dynamic healing responses following acute traumatic rupture. Our histological findings suggest that surgical treatment of acute ACJ dislocations should be performed as early as possible within a timeframe of 1 week after trauma to exploit the utmost biological healing potential. Prospective clinical studies are warranted to investigate whether early surgical treatment of ACJ dislocations translates into clinical benefits.

Surgical treatment of acute Rockwood III acromioclavicular dislocations-Comparative study between two flip-button techniques

Acromioclavicular joint dislocation is a common shoulder injury, usually caused by direct violence on the shoulder. Optimal treatment of type III is still a hot discussion currently in orthopedic surgeons. With the advent of many flip-button techniques, Tightrope system and Endobutton system become popular techniques for reconstruction of coracoclavicular ligaments. The purpose of the study was to compare the clinical and radiological results between the two techniques. A retrospective case-control study was conducted in 60 patients with acute Rockwood III acromioclavicular joint dislocation. The two techniques conducted were open procedures using Twin Tail Tightrope system (Group A, n = 30) and Endobutton system (Group B, n = 30). 60 patients were followed up at least two years. Surgical parameters including incision length, operation time and operative blood loss were analyzed. Functional outcomes were evaluated using the Constant-Murley Score. Radiological results were assessed based on coracoclavicular distance preoperatively, one day postoperatively, and at the final follow-up. 60 patients were followed up for at least 24 months (range 24 to 32). The incision length and operation time were shorter in Group A than that in Group B. The blood loss of surgery was significantly less in the Group A. There were no significant differences between the two groups regarding the Constant-Murley Score at the final follow-up. No significant differences were found in the coracoclavicular distance preoperatively, immediately postoperatively, and at the final follow-up. Both techniques offered satisfying functional outcomes, however the Tightrope system provided better surgical parameters.

Coracoid clavicular tunnel angle is related with loss of reduction in a single-tunnel coracoclavicular fixation using a dog bone button in acute acromioclavicular joint dislocation

PURPOSE

Despite the high failure rates of techniques used to maintain the reduction of single-tunnel coracoclavicular (CC) fixation, analyses of the etiology of loss of reduction related to surgical techniques are limited. Therefore, it was hypothesized that the initial coracoclavicular tunnel angle was related to loss of reduction in the single-tunnel technique for AC joint dislocation. This study aimed to evaluate the clinical and radiological outcomes of arthroscopic single-tunnel CC suture button fixation according to the initial coracoclavicular tunnel angle.

METHODS

Thirty-two consecutive patients who underwent arthroscopic single-tunnel CC suture button fixation for AC joint dislocation from 2014 to 2018 were enrolled. The tunneling-first technique was used in the first 11 patients, while the reduction-first technique was used in the remaining 22 consecutive patients. For clinical assessments, the American Shoulder and Elbow Surgeons (ASES) score and Korean Shoulder Score (KSS) were recorded. For radiological evaluation, coracoclavicular distance ratio, coracoclavicular tunnel angle, coracoid, and clavicular tunnel widths were measured.

RESULTS

The ASES score did not differ significantly between the two groups (n.s.). However, the KSS was significantly better in the reduction-first group (p = 0.031). No significant intergroup differences were observed in the pre- and postoperative coracoclavicular distance ratio. However, at the last follow-up, loss of coracoclavicular distance ratio was significantly smaller in the reduction-first group (p < 0.001). At the final follow-up, loss of the coracoclavicular distance ratio was positively correlated with the postoperative coracoclavicular tunnel angle (p < 0.001, Spearman's rho correlation coefficient = 0.602). The final follow-up clavicular tunnel width was also significantly smaller in the reduction-first group (p = 0.002). Finally, the last follow-up clavicular tunnel width was positively correlated with the postoperative coracoclavicular tunnel angle (p = 0.008, Spearman's rho correlation coefficient = 0.459).

CONCLUSION

The reduction-first technique showed better clinical and radiological outcomes than the tunneling-first technique in single-tunnel CC fixation for AC joint dislocation. A large postoperative coracoclavicular tunnel angle was associated with loss of reduction and clavicular tunnel widening. Therefore, obtaining a straight coracoclavicular tunnel angle is crucial for achieving better outcomes and minimizing loss of reduction.

LEVEL OF EVIDENCE

III.

The importance of biomechanical properties in revision acromioclavicular joint stabilization: a scoping review

PURPOSE

Treatment of failed primary reconstruction of the unstable acromioclavicular (AC) joint remains challenging for orthopaedic surgeons. When approaching revision cases, the reason for failure has to be precisely identified. The purpose of this manuscript was to perform a critical review of the literature regarding treatment options for failed AC joint stabilization techniques and to provide a treatment algorithm for salvage procedures.

METHODS

A thorough search included electronic databases for articles published up to April 15th, 2019. Inclusion criteria were set as (1) studies that reported on clinical outcomes following surgical or conservative treatment of AC joint dislocation; (2) studies reporting on failure or complications of primary treatment; (3) chronic instabilities caused by delayed or secondary treatment as well as (4) revision and salvage procedures.

RESULTS

The search strategy identified a total of 3269 citations. The final dataset comprised 84 studies published between 1954 and 2019. A total of 5605 patients (9.63% females) were involved with a mean age of 34.5 years. Overall, complication rates varied between 5 and 88.9% in patients with AC joint instability.

CONCLUSION

In the current literature, evidence for treatment of revision AC joint instability is still lacking, however, surgical treatment continues to evolve. The importance of failure analysis and clinically relevant algorithms were highlighted in this review. Adequately restoring native joint biomechanics is needed for ensuring an optimal healing environment that will translate into patient satisfaction and long-term stability.

LEVEL OF EVIDENCE

V.

Acromioclavicular joint augmentation at the time of coracoclavicular ligament reconstruction fails to improve functional outcomes despite significantly improved horizontal stability

PURPOSE

Acromioclavicular joint reconstruction is a well-established and frequently performed procedure. Recent scientific and commercial interest has led to a drive to develop and perform surgical techniques that more reliably restore horizontal stability in order to improve patient outcomes. The aim of this systematic review was to evaluate the biomechanical evidence for procedures directed at restoring horizontal stability and determine whether they are associated with superior clinical results when compared to well-established procedures.

METHODS

A review of the online databases Medline and EMBASE was conducted in accordance with the PRISMA guidelines on the 23rd December 2017. Biomechanical and clinical studies reporting either static or dynamic horizontal displacement following acromioclavicular joint reconstruction (Coracoclavicular reconstruction or Weaver-Dunn) were included. In addition, biomechanical and clinical studies reporting outcomes after additional augmentation of the acromioclavicular joint were included. The studies were appraised using the Methodological index for non-randomised studies tool.

RESULTS

The search strategy identified 18 studies eligible for inclusion: six biomechanical and 12 clinical studies. Comparative biomechanical studies demonstrated that acromioclavicular augmentation provided significantly increased horizontal stability compared to the coracoclavicular reconstruction and Weaver-Dunn procedure. Comparative clinical studies demonstrated no significant differences between coracoclavicular reconstruction with and without acromioclavicular augmentation in terms of functional outcomes (American Shoulder and Elbow Surgeon and Constant score), complication or revision rates. However, one comparative study did demonstrate an improvement in Taft (p = 0.018) and Acromioclavicular Joint Instability scores (p = 0.0001) after acromioclavicular augmentation.

CONCLUSION

In conclusion, coracoclavicular reconstruction with augmentation of the acromioclavicular joint has been shown to provide improved horizontal stability in both biomechanical and clinical studies compared to isolated coracoclavicular reconstruction. However, comparative studies have shown no clinical advantage with respect to American Shoulder and Elbow Surgeon or Constant scores and, therefore, the results of this systematic review do not support acromioclavicular augmentation in routine clinical practice.

LEVEL OF EVIDENCE

IV.

Arthroscopically assisted acromioclavicular joint stabilization leads to significant clavicular tunnel widening in the early post-operative period

PURPOSE

Arthroscopically assisted acromioclavicular joint (ACJ) stabilization techniques use bone tunnels in the clavicle and coracoid process. The tunnel size has been shown to have an impact on the fracture risk of clavicle and coracoid. The aim of the present study was to radiographically evaluate the alterations of the clavicular tunnel size in the early post-operative period. It was hypothesized that there would be a significant increase of tunnel size.

METHODS

Twenty consecutive patients with acute high-grade ACJ (Rockwood type IV-V) injury underwent arthroscopic-assisted ACJ stabilization. The median age of the patients was 40 (26-66) years. For all patients, a single tunnel button-tape construct was used along with an additional ACJ tape cerclage. Radiologic measurements were undertaken on standardized Zanca films at two separate time points, immediate post-operative examination (IPO) and at late post-operative examination (> 4 months; LPO). The LPO radiographs were taken at a median follow-up period of 4.5 (3-6) months. Clavicular tunnel width (CT) and coracoclavicular distance (CCD) were measured using digital calipers by two independent examiners and the results are presented as median, range, and percentage.

RESULTS

The median CCD increased significantly from 9.5 (8-13) mm at IPO to 12 (7-20) mm at LPO (p < 0.05). Median tunnel size showed significant difference from 3 (3-4) mm at IPO to 5 (4-7) mm at LPO (p < 0.05). Despite a significant increase of 2 mm (66.6%) of the initial tunnel size, there was no correlation between tunnel widening and loss of reduction.

CONCLUSION

Arthroscopic ACJ stabilization with the use of bone tunnels led to a significant increase of clavicular tunnel size in the early post-operative period. This phenomenon carries a higher fracture risk, especially in high-impact athletes, which needs to be considered preoperatively.

LEVEL OF EVIDENCE

IV.

The Diagnosis and Treatment of Acute Dislocation of the Acromioclavicular Joint

BACKGROUND

The acromioclavicular joint (ACJ) is one of the more common sites of shoulder girdle injury, accounting for 4-12% of all such injuries, with an incidence of 3-4 cases per 100 000 persons per year in the general population. Current topics of debate include the proper standard diagnostic evaluation, the indications for surgery, and the best operative method.

METHODS

This review is based on publications retrieved by a selective literature search.

RESULTS

Mechanical trauma of the ACG can tear the ligamentous apparatus that holds the acromion, clavicle, and coracoid process together. Different interventions are indicated depending on the nature of the injury. In recent years, the horizontal component of the instability has received more attention, in addition to its vertical component. Persistent instability can lead to chronic, painful limitation of shoulder function, particularly with respect to working above the head. Surgical stabilization is therefore recommended for high-grade instability of Rockwood types IV and V. Modern reconstruction techniques enable selective vertical and horizontal treatment of the instability and have been found superior to traditional methods, particularly in young athletes. Arthroscopic techniques are advantageous because they are less invasive, do not require removal of implanted material, and afford the opportunity to diagnose any accompanying lesions definitively and to treat them if necessary. Surgery for acute injuries should be performed within three weeks of the trauma. For chronic injuries, additional tendon augmentation is now considered standard treatment.

CONCLUSION

High-grade ACJ instability is a complex and significant injury of the shoulder girdle that can cause persistent pain and functional impairment. The state of the evidence regarding its optimal treatment is weak. Large-scale, prospective, randomized comparative studies are needed in order to define a clear standard of treatment.

Anatomic ligament consolidation of the superior acromioclavicular ligament and the coracoclavicular ligament complex after acute arthroscopically assisted double coracoclavicular bundle stabilization

PURPOSE

The consolidation of the acromioclavicular (AC) and coracoclavicular (CC) ligament complex after arthroscopically assisted stabilization of acute acromioclavicular joint (ACJ) separation is still under consideration.

METHODS

Fifty-five consecutive patients after arthroscopically assisted double-CC-bundle stabilization within 14 days after acute high-grade ACJ separation were studied prospectively. All patients were clinically analysed preoperatively (FU0) and post-operatively (FU1 = 6 months; FU2 = 12 months). The structural MRI assessments were performed at FU0 (injured ACJ) and at FU2 bilateral (radiologic control group) and assessed separately the ligament thickness and length at defined regions for the conoid, trapezoid and the superior AC ligament.

RESULTS

Thirty-seven patients were assessed after 6.5 months and after 16.0 months. The 16-month MRI analysis revealed for all patients continuous ligament healing for the CC-complex and the superior AC ligament with in the average hypertrophic consolidation compared to the control side. Separate conoid and trapezoid strands (double-strand configuration) were detected in 27 of 37 (73%) patients, and a single-strand configuration was detected in 10 of 37 (27%) patients; both configurations showed similar CCD data. The ligament healing was not influenced by the point of surgery, age at surgery and heterotopic ossification. The clinical outcome was increased (FU0-FU2): Rowe, 47.7-97.0 pts.; TAFT, 3.9-10.6 pts.; NAS _pain, 8.9-1.4 pts. (all P < 0.05).

CONCLUSION

The arthroscopically assisted double-CC-bundle stabilization within 14 days after acute high-grade ACJ separation showed 16 months after surgery sufficient consolidations of the AC and double-CC ligament complex in 73%.

LEVEL OF EVIDENCE

III, Case series.

Factors Predicting the Outcome After Arthroscopically Assisted Stabilization of Acute High-Grade Acromioclavicular Joint Dislocations

BACKGROUND

Factors influencing the outcome after arthroscopically assisted stabilization of acute high-grade acromioclavicular (AC) joint dislocations remain poorly investigated.

PURPOSE

To identify determinants of the radiological outcome and investigate associations between radiological and clinical outcome parameters.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors performed a retrospective analysis of patients who underwent arthroscopically assisted stabilization for acute high-grade AC joint dislocations. The following potential determinants of the radiological outcome were examined using univariable and multivariable regression analyses: timing of surgery, initial AC joint reduction, isolated coracoclavicular (CC) versus combined CC and AC stabilization, ossification of the CC ligaments, age, and overweight status. In addition, associations between radiological (ie, CC difference, dynamic posterior translation [DPT]) and clinical outcome parameters (Subjective Shoulder Value, Taft score [TS] subjective subcategory, and Acromioclavicular Joint Instability Score [ACJI] pain subitem) were evaluated using univariable analysis.

RESULTS

One hundred four patients with a mean (±SD) age of 38.1 ± 11.5 years were included in this study. The mean postoperative follow-up was 2.2 ± 0.9 years. Compared with patients with an overreduced AC joint after surgery, the CC difference was 4.3 mm (95% CI, 1.3-7.3; P = .006) higher in patients with incomplete reduction. Patients with anatomic reduction were 3.1 times (95% CI, 1.2-7.9; P = .017) more likely to develop DPT than those with an overreduced AC joint. An incompletely reduced AC joint was 5.3 times (95% CI, 2.1-13.4; P < .001) more likely to develop DPT versus an overreduced AC joint. Patients who underwent isolated CC stabilization were 4.8 times (95% CI, 1.1-21.0; P = .039) more likely to develop complete DPT than patients with additional AC stabilization. Significantly higher CC difference values were noted for patients who reported pain on the subjective TS (P = .025). Pain was encountered more commonly in patients with DPT (P_TS = .049; P_ACJI = .038).

CONCLUSION

Clinicians should consider overreduction of the AC joint because it may lead to favorable radiological results. Because of its association with superior radiographic outcomes, consideration should also be given to the use of additional AC cerclage.

Arthroscopic Coracoclavicular and Acromioclavicular Stabilization of Acute Acromioclavicular Joint Dislocation By Suspensory Fixation System

Arthroscopic stabilization of acute acromioclavicular joint dislocations using coracoclavicular suspension techniques has become more popular, but lack of horizontal stability is a major concern that furthermore affects the final outcome. We present an arthroscopic technique to stabilize acute acromioclavicular joint dislocations in both the vertical and horizontal planes, with better results than conventional coracoclavicular suspension techniques.

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.

Arthroscopic Acromioclavicular Fixation With Suture Tape Augmentation After Coracoclavicular Fixation With Dog Bone Button: Surgical Technique

An arthroscopic technique for the surgical treatment of acute acromioclavicular (AC) joint injuries is presented in this study. This procedure aims to achieve both vertical and horizontal stability through the healing of both coracoclavicular (CC) and AC ligaments. As a routine maneuver, arthroscopic CC stabilization was applied using the dog bone button to obtain only vertical stability. Additional arthroscopic AC joint fixation with suture tape augmentation is simple and easy and provides a safe technique to achieve horizontal stability of the joint and to increase the vertical stability to minimize the complications of standard CC reconstruction techniques.

Biomechanical Comparison of Anatomic and Extra-Anatomic Reconstruction Techniques Using Local Grafts for Chronic Instability of the Acromioclavicular Joint

BACKGROUND

Anatomic reconstruction techniques are increasingly used to address cases of acromioclavicular (AC) joint chronic instability. These usually involve an additional surgical site for autograft harvesting or an allograft.

PURPOSE

To describe a triple-bundle (TB) anatomic reconstruction using on-site autografts, the semiconjoint tendon (SCT) and the coracoacromial ligament (CAL), and compare its primary stability to the native AC joint ligamentous complex and to a modified Weaver-Dunn (WD) reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Intact AC joints of 12 paired cadaveric shoulders were tested for anterior, posterior, and superior translations under cyclic loading with a servo-hydraulic testing system. One shoulder from each pair was randomly assigned to the TB group, where 2 SCT strips were used to reconstruct the coracoclavicular ligaments while the distal end of the CAL was transferred to the distal extremity of the clavicle to reconstruct the AC ligaments; the other shoulder received a modified WD reconstruction. After reconstruction, the same translational testing was performed, with an additional load-to-failure test in the superior direction.

RESULTS

In both the TB and the WD groups, no significant differences were found before and after reconstruction in terms of joint displacements after cyclic loading, in all 3 directions. Compared with the WD reconstruction, the TB repair resulted in significantly lower displacements in both the anterior (ie, 2.59 ± 1.08 mm, P = .011) and posterior (ie, 10.17 ± 6.24 mm, P = .014) directions, but not in the superior direction. No significant differences were observed between the 2 reconstructions during the load-to-failure testing, except for the displacement to failure, which was significantly smaller (ie, 5.34 ± 2.97 mm) in the WD group ( P = .037).

CONCLUSION

Anterior, posterior, and superior displacements after an anatomic reconstruction of the AC joint complex using the SCT and CAL as graft material were similar to those of native AC joints and significantly smaller in the axial plane than those of AC joints after a WD repair.

CLINICAL RELEVANCE

An anatomic reconstruction is achievable using the CAL and the SCT as on-site graft materials, providing satisfactory initial stability and thereby allowing earlier mobilization.

A retrospective comparative study of arthroscopic fixation in acute Rockwood type IV acromioclavicular joint dislocation: single versus double paired Endobutton technique

Background

Rockwood type IV acromioclavicular joint (ACJ) dislocation is a trauma usually needs surgical treatment. Paired EndoButton technique (PET) is used in treating such condition. However, the effect of using different types of PET (single versus double PET) for fixation remains controversial. This study aims to evaluate and compare the efficacy of single and double PET and to provide a suitable option for the surgeons.

Methods

We retrospectively reviewed the charts of patients with acute Rockwood type IV ACJ dislocation who had undergone arthroscopic fixation using single or double PET fixation between March 2009 and March 2015. Seventy-eight consecutive patients identified from chart review were picked and were divided into the single and double PET group with 39 cases in each group. The indexes of visual analog scale score (VAS) for pain, the radiographs of the affected shoulder at different time points of the follow-up, the time of return to activities and sports, the constant functional score, and the Karlsson acromioclavicular joint (ACJ) score, were assessed in a minimum of 2 years postoperation.

Results

The average coracoclavicular (CC) and acromioclavicular (AC) distances of the affected joints in the double PET group were significantly smaller than those of the single PET group 2 years postoperation (P < 0.05). The average AC and CC distances in the healthy shoulder joints were significantly smaller than those of the affected joints in the single PET group (P < 0.05); however, these values were not significantly different from those of the affected joints in the double PET group (P > 0.05). The mean VAS pain score was not significantly different, while significant difference was found for the number and times of cases return to activities and sports, constant functional score, and Karlsson ACJ score (P < 0.05) between the two groups. Therefore, the double PET group has better outcome than the single PET group. Complications including redislocation, button slippage, erosion, or AC joint instability occurred in the single PET group, while the complication in the double PET group was rare.

Conclusions

Compared with the single PET, the double PET group achieved better outcome with less complications in arthroscopically treating acute Rockwood type IV ACJ dislocation.

Biplanar fixation of acromio-clavicular joint dislocation associated with coracoid process fracture: Case report

Introduction

Acromioclavicular (AC) joint injury associated with coracoid process (CP) fracture is a rare injury and only case reports had been published in the literature. Although AC joint injury is not uncommon, there is controversy as regard the best stabilization method whether to use wires, hook plate, arthroscopic reconstruction or the recently described techniques of anatomic restoration of both the coracoclavicular (CC) and acromioclavicular (AC) ligaments to add stability in both the vertical as well as the horizontal plane for the AC joint. Isolated CP fracture rarely necessitates surgical intervention; but in association with AC joint injury; a controversy as regard best management, surgical approach, technique of stabilization and implant used is present due to paucity of literature.

Patient and method

A 36 years old manual worker who sustained a combined injury of AC joint (grade III) and CP comminuted base fracture had been treated surgically in our hospital using a biplanar fixation technique; blind 4 mm cannulated screw for the CP fracture and anatomic reconstruction of the AC ligament using FibreTape (Arthrex, Naples, FL); to add stability in both the vertical and horizontal plane. Follow up was done for one year.

Results

After completion of rehabilitation program, patient could return to work with no shoulder pain in ten weeks postoperatively. Till the last follow up there was no evidence of loss of reduction or shoulder pain with a Constant score of 86.

Conclusion

Our technique in combined AC joint and CP fracture, address both injuries to add biplanar AC joint stability allowing accelerated rehabilitation and avoids metal hardware complications.

Acromioclavicular joint dislocation: a Dog Bone button fixation alone versus Dog Bone button fixation augmented with acromioclavicular repair-a finite element analysis study

BACKGROUND

Suspension suture button fixation was frequently used to treat acromioclavicular joint (ACJ) dislocation. However, there were many studies reporting about complications and residual horizontal instability after fixation. Our study compared the stability of ACJ after fixation between coracoclavicular (CC) fixation alone and CC fixation combined with ACJ repair by using finite element analysis (FEA).

MATERIALS AND METHODS

A finite element model was created by using CT images from the normal shoulder. The model 1 was CC fixation with suture button alone, and the model 2 was CC fixation with suture button combined with ACJ repair. Three different forces (50, 100, 200 N) applied to the model in three planes; inferior, anterior and posterior direction load to the acromion. The von Mises stress of the implants and deformation at ACJs was recorded.

RESULTS

The ACJ repair in the model 2 could reduce the peak stress on the implant after applying the loading forces to the acromion which the ACJ repair could reduce the peak stress of the FiberWire at suture button about 90% when compared to model 1. And, the ACJ repair could reduce the deformation of the ACJ after applying the loading forces to the acromion in both vertical and horizontal planes.

CONCLUSION

This FEA supports that the high-grade injuries of the ACJ should be treated with CC fixation combined with ACJ repair because this technique provides excellent stability in both vertical and horizontal planes and reduces stress to the suture button.

Triple-bundle anatomical reconstruction using the coracoacromial ligament and the short head of biceps tendon to stabilize chronic acromioclavicular joint dislocations: A cadaver feasibility study

INTRODUCTION

In cases of chronic acromioclavicular joint separation, the biomechanical properties of anatomical reconstructions are closer to the native configuration than the Weaver-Dunn procedure. Consequently, the radiological and clinical outcomes are better. However, an additional incision is needed to harvest the graft, which increases the procedure's morbidity.

HYPOTHESIS

Triple-bundle reconstruction can be performed with the coracoacromial ligament (CAL) and the semi conjoined tendon (SCT).

MATERIAL AND METHODS

Bilateral dissection was performed on the upper limb of six fresh-frozen cadavers. Measurements useful to the procedure were taken on one limb, specifically the minimum graft length needed and the available length. The surgical procedure was performed on the other limb. The proximally based SCT was passed through the base of the coracoid process, then divided into two strips tightened from the superior aspect of the coracoid process to the clavicular insertion points of the conoid and trapezoid ligaments. The CAL was detached from the coracoid process and then secured in the medullary canal of the clavicle, after its lateral one-quarter was resected (i.e., 10mm).

RESULTS

The mean length of the SCT was 101.7±7.6mm (95.1-114.5) and the mean length of the CAL was 35.3±4.7mm (28.7-42.5). The SCT length needed for this reconstruction was 58±4.3mm (51.5-62) medially and 60.3±4.6mm (54.3-66.3) laterally. The procedure was feasible in all six cadavers with an average excess length of 39.9±5.7mm (32.2-47) for the conoid bundle, 37.6±5mm (31-45.1) for the trapezoid ligament and 6±2.7mm (3-9.5) for the CAL.

DISCUSSION

Triple-bundle anatomical reconstruction using the SCT and CAL is feasible. However, the strength of this construct must be evaluated biomechanically before it can be used clinically.

LEVEL OF EVIDENCE

Not applicable - cadaver study.

Arthroscopically assisted reduction of acute acromioclavicular joint dislocation using a single double-button device: Medium-term clinical and radiological outcomes

INTRODUCTION

Double-button devices for endoscopic management of acute acromioclavicular joint dislocation (ACJD) provide satisfactory short-term functional and radiological results. However, little exists in the literature regarding the long- and medium-term results of these implants, especially regarding the evolution of the acromioclavicular joint (ACJ).

HYPOTHESIS

Satisfactory and steady long- and medium-term outcomes can be achieved in patients with acute ACJD undergoing endoscopically assisted ACJ repair using a single double-button device.

MATERIAL AND METHOD

A retrospective single-center study was conducted in patients with acute Rockwood III and IV ACJD treated endoscopically with a single double-button device from October 2008 to October 2010, allowing a minimum 5-year follow-up. Functional evaluation used Constant and Quick-DASH scores. Clinical evidence of dislocation recurrence was combined with bilateral Zanca views to assess coracoclavicular distance. Acromioclavicular osteoarthritis was evaluated on the Paxinos test and Zanca views.

RESULTS

Nineteen of the 25 operated patients were seen at a mean 76.9±8.5 months' follow-up. Mean age was 34.4±8.3 years. Mean Constant and Quick-DASH scores were 96.2±5.1 and 0.9±1.6 points, respectively. Four patients had a recurrence of their initial dislocation, 3 of whom had positive Paxinos test, whereas the 15 patients without recurrence had a negative test (p=0.004). Five patients had radiological evidence of ACJ osteoarthritis: all 4 patients with recurrence and 1 without (p=0.001).

CONCLUSION

Long- and medium-term radioclinical outcome of endoscopically assisted management of acute ACJD using a single double-button device seems to be satisfactory and steady over time. Recurrence of the initial dislocation appears to be related to onset of degenerative ACJ arthropathy.

LEVEL OF EVIDENCE

Therapeutic type IV-Retrospective case series.

A comparison between two double-button endoscopically assisted surgical techniques for the treatment acute acromioclavicular dislocations

PURPOSE

To compare clinical and radiological outcomes between two endoscopically assisted double-button techniques in high-grade acute acromioclavicular separations.

METHODS

A retrospective single-center study was conducted in patients with acute acromioclavicular joint dislocation Rockwood types III and V, from 2009 to 2014. All were treated endoscopically, with a 1-year minimum follow-up. Two consecutive series were conducted; the first (TR group) received the TightRope^® system, whereas last series (DB group) was treated with the Dog Bone^® button technology (Arthrex, Naples, FL, USA). Primary endpoints were last follow-up values of Constant score (CS) and Quick-DASH (QD) score. Moreover, the posttraumatic displacement and its evolution were assessed on bilateral Zanca radiographs. A displacement of 5 mm or greater the day after surgery was considered as a lack of reduction; the same difference on last follow-up X-rays was considered as a loss of reduction.

RESULTS

Forty patients were reviewed: 22 in the TR group and 18 in the DB group. After a mean follow-up of 27.7 ± 8.3 months, CS and QD averaged, respectively, 94.3 ± 4.4 and 2.0 ± 2.6 in the TR series, whereas they averaged, respectively, 95 ± 6.1 and 3.4 ± 3.3 in the DB series after a mean follow-up of 24.1 ± 5 months (PCS = 0.16, PQDS = 0.08). Lack of reduction and loss of reduction rates were significantly higher in the DB group, with P = 0.0005 and P < 0.0001, respectively.

CONCLUSIONS

Both techniques provided good to excellent functional outcomes. However, considering inferior radiological results using the Dog Bone^® device, we would prefer the TightRope^® device in acute acromioclavicular dislocations.

LEVEL OF EVIDENCE

IV: Therapeutic study-cases series.

Arthroscopic-assisted Acromioclavicular and Coracoclavicular Ligaments Reconstruction for Chronic Acromioclavicular Dislocations: Surgical Technique

Chronic acromioclavicular (AC) instability is a rare posttraumatic shoulder condition that can lead to undesirable symptoms like persistent pain, muscle fatigue, loss of strength, or even scapular dyskinesis. It is well known that in these cases the superior functional results depend on the restoration of the anatomy and stability of the AC joint in both vertical and horizontal planes. Considering the ligaments degeneration and atrophy in chronic AC joint dislocations, we present an arthroscopic-assisted reconstruction of both the coracoclavicular and AC ligaments using autograft augmentation. In details the coracoclavicular ligaments component is reconstructed using the Tightrope suspension device augmented with a palmaris longus autograft and by the nonanatomic coracoacromial ligament transfer (modified Weaver-Dunn). The AC part is restored by suturing the remainder palmaris longus autograft on the acromion and on the deltotrapezial fascia. Using the construct provided by this technique all the possible ruptured ligaments are reconstructed, optimizing the vertical and horizontal stability of the area, and promising excellent long-term radiologic and functional results.

Long-term outcomes of tension band wiring with a single K-wire in Rockwood type IV/V acute acromio-clavicular dislocations: 25 cases

BACKGROUND

Our objective was to evaluate the long-term functional and radiological outcomes of tension band wiring with a single K-wire for acute Rockwood types IV and V acromio-clavicular dislocation (ACD).

METHODS

Single-centre cross-sectional non-randomised observational cohort study of 25 shoulders treated surgically between January 2002 and December 2004, in 25 patients, 23 males and 2 females, with a mean age of 35±11years (24-46). The evaluation criteria were the absolute and weighted Constant scores, QuickDASH score, subjective shoulder value (SSV), visual analogue scale (VAS) pain score at rest and during activities, and radiographic features in clinically symptomatic patients.

RESULTS

Mean values were as follows: follow-up, 150±17months (133-167); absolute Constant score, 88±17 (71-105); weighted Constant score, 92.5±12.5 (80-105); QuickDASH, 15.5±7 (8.5-22.5); SSV, 88±17% (71-105); VAS pain score at rest, 0.2±0.7 (0-0.9); and VAS pain score while active, 1.4±2.3 (0-3.7). The weighted Constant score was less than 70% in only 8% of patients. Of the 17 patients for whom radiographs were obtained, 8 had acromio-clavicular osteoarthritis. Mean coraco-clavicular distance was 12.3±4.3mm (8-16.6) and mean acromio-clavicular distance was 5±5mm (0-10). The recurrence rate was 8%.

CONCLUSION

Tension band wiring with a single K-wire for acute acromio-clavicular dislocation reliably provides good long-term functional outcomes. Recurrences are uncommon and few patients experience symptoms (8%).

LEVEL OF EVIDENCE

IV, retrospective study.