Comparative study on the treatment of Rockwood type III acute acromioclavicular dislocation: Clinical results from the TightRope® technique vs. K-wire fixation

Choice of Acromioclavicular Dislocation Treatment Should Not Be Influenced by Risk of Development of Acromioclavicular Osteoarthritis: A Systematic Review With Meta-Analysis

BACKGROUND

It is currently unknown to what degree surgical or nonoperative treatment of acromioclavicular (AC) dislocation influences the development of osteoarthritis (OA). The aim of this study was to evaluate AC OA after surgical and nonoperative treatment for AC dislocations, compare OA prevalence between treatment options, and compare OA prevalence between the injured and contralateral shoulder.

METHODS

Articles reporting on the prevalence of OA after surgical or nonoperative treatment of an AC dislocation with a minimal 2-year follow-up were included. AC OA presence was extracted for the injured and contralateral shoulder. Treatment categories were defined based on anatomical variation in the reattachment of ligaments: AC fixation, coracoclavicular (CC) fixation, AC and CC fixation, Bosworth screw synthetic graft, tendon graft, and conservative. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Ninety-four articles were included for qualitative analysis, and 7 articles were included for meta-analysis (n = 3,812; follow-up = 2.0-24.2 years; mean age 37.6 ± 10.4 years). A total of 3,483 patients underwent surgical treatment, and 329 patients underwent conservative treatment. OA prevalence ranged from 6.7%-29.3% between 7 pooled treatment categories. Most included studies had a follow-up <10 years (94%) and OA prevalence increased with time, regardless of treatment option. There was no difference in OA prevalence between the injured and contralateral shoulder (p = 0.120). MINORS scores were varied, ranging from poor to very good.

CONCLUSION

The pooled AC OA prevalence of the 7 treatment categories ranged from 6.7% for the CC fixation surgical group to 29.3% for the conservative treatment group. However, the included studies were predominantly of low quality and had varying follow-up periods, with most having relatively short follow-up durations. No difference in AC OA prevalence was found between the injured and contralateral shoulder. Based on the available evidence, treatment choice for AC dislocation should not be influenced by the potential development of AC AO.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Minimally Invasive Techniques for the Treatment of Acute and Chronic Acromioclavicular Joint Instabilities]

Acromioclavicular joint instabilities are one of the most common injuries of the shoulder girdle. Diagnostic measures include the vertical and horizontal components of instability. The main goals of treatment include pain reduction, joint stabilization, and return to physical activity. For operative treatment, there are numerous techniques available. Recently, minimally-invasive techniques were developed and showed equal results as with open approach. These procedures facilitate simultaneous treatment of concomitant shoulder lesions and reduce soft tissue trauma as well as the risk of infection. This article presents an overview of such minimally-invasive techniques for both acute and chronic instabilities. Both techniques address the aspect of horizontal instability, which was found to compromise clinical results. For an acute injury, we describe the use of a low-profile button system combined with an additional acromioclavicular cerclage. In the chronic setting with a bidirectional (vertical and horizontal) instability, a free tendon graft combined with a single TightRope augmentation is recommended.

Single tunnel technique versus coracoid sling technique for arthroscopic treatment of acute acromioclavicular joint dislocation

To evaluate and compare the efficacy of two techniques for the treatment of acute acromioclavicular joint dislocation, the charts of 60 patients diagnosed with acute Rockwood type IV and V acromioclavicular joint dislocation that undergone arthroscopic fixation procedure with single tunnel technique (N = 30, 30.7 ± 5.7 years old) or coracoid sling technique (N = 30, 30.1 ± 5.4 years old) fixation were retrospectively reviewed. The Visual Analog Scale pain score, Constant shoulder functionality score, Karlsson acromioclavicular joint score, the time of return to sports and activity, and plain radiographs of the affected shoulder at different time points of follow-up were recorded for a minimum of 2 years post-op. The majority of the patients recovered to their preoperative activity levels with few complications. The average postoperative acromioclavicular and coracoclavicular distances were significantly narrower than preoperative measurements in both groups without significant difference between the two groups at 2 years post-op (P < 0.05). The coracoid sling technique group had reduced operative time, shorter time of recovery of shoulder movements, higher Constant functionality scores and Karlsson acromioclavicular joint scores, and fewer complications than the single tunnel technique group at the last follow-up (P < 0.05). Therefore, coracoid sling technique achieved superior clinical outcomes with fewer complications compared to the traditional single tunnel technique in arthroscopic treatment of acute acromioclavicular joint dislocation.

Clinical and radiological outcomes of acute Rookwood type IIIB acromioclavicular joint dislocation: Mini-open tightrope technique versus hook plate

OBJECTIVE

Treatment of acute Rookwood type III AC joint dislocation is still controversially discussed. ISAKOS suggested to subdivide type III AC joint injuries into type IIIA (stable) and type IIIB (unstable). The aim of this study was to compare clinical and radiographic outcomes between hook plate fixation and mini-open tightrope for the treatment of acute Rookwood type IIIB acromioclavicular joint dislocation.

METHODS

We conducted a retrospective clinical study of 112 patients with acute Rookwood type IIIB acromioclavicular joint dislocation who were treated surgically using either mini-open TightRope or hook plate from 2013 to 2019. All patients were followed up for 12 months. Clinical outcomes were evaluated using Visual Analogue Scale (VAS) and the Constant-Murley Score (CMS). Radiological results were assessed with the coracoclavicular distance (CCD), the change in clavicular elevation (ΔCE) and horizontal translation.

RESULTS

The length of incision was significantly shorter in the mini-open TightRope group than that in hook plate group (6.62±0.60 vs. 2.58±0.43 p <0.001). Duration of surgery was significantly shorter in the mini-open TightRope group than that in hook plate group (30.12±6.65 vs. 53.33±12.03; p < 0.001). Total blood loss volume was significantly less in the mini-open TightRope group than in the hook plate group. (23.85±7.88 vs. 70.67±24.62, p < 0.001). VAS and CMS in mini-open TightRope group were better than that in hook plate group at 2 weeks after surgery (VAS: 2.19±0.92 vs. 3.30±1.51, p = 0.002 and CMS 69.80±5.61 vs. 57.53±9.24, p<0.001) and 3 month after surgery (VAS: 1.19±0.48 vs. 3.07±1.36, p<0.001 and CMS 89.30±4.47 vs. 83.20±12.11, p = 0.205). There was no statistically significant difference between two groups at 12 months follow-up including VAS, CMS, the CC distance,ΔCE and the degree of dynamic horizontal translation. There were 2 complications in the hook plate group including 1cut out and 1 superficial wound infection.

CONCLUSION

The mini-open tightrope has better function and relieves pain in the early postoperative period compared to hook plate, and at the last follow up two groups have similar clinical and radiological outcomes. Mini-open TightRope fixation is a good option for the treatment of acute Rockwood types ⅢB AC joint dislocation.

Grade III Acromioclavicular Separations Treated With Suspensory Fixation Techniques: A Systematic Review of Level I Through IV Studies

Purpose

To perform a systematic review comparing clinical outcomes, radiographic outcomes, and complication rates after acute (surgery ≤6 weeks from injury) versus chronic (surgery >6 weeks from injury) acromioclavicular joint reconstructions for grade III injuries using modern suspensory fixation techniques.

Methods

We performed a systematic review of the literature examining acute versus chronic surgical treatment of Rockwood grade III acromioclavicular joint separations using the Cochrane registry, MEDLINE database, and Embase database over the past 10 years according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria included techniques using suspensory fixation, a minimum study size of 3 patients, a minimum follow-up period of 6 months, human studies, and English-language studies. The methodology of each study was evaluated using the Methodological Index for Non-randomized Studies (MINORS) tool for nonrandomized studies and the revised Cochrane risk-of-bias (RoB 2) tool for randomized controlled trials.

Results

The systematic review search yielded 20 studies with a total of 253 patients. There were 2 prospective randomized controlled trials, but most of the included studies were retrospective. On comparison of acute surgery (≤6 weeks) and chronic surgery (>6 weeks), individual studies reported a range of Constant scores of 84.4 to 98.2 and 80.8 to 94.1, respectively. The ranges of radiographic coracoclavicular distances reported at final follow-up also favored acute reconstructions, which showed improved reduction (9.2-15.7 mm and 11.7-18.6 mm, respectively). The reported complication rates ranged from 7% to 67% for acute reconstructions and from 0% to 30% for chronic reconstructions.

Conclusions

The ranges in the Constant score may favor acute reconstructions, but because of the heterogeneity in the surgical techniques in the literature, no definitive recommendations can be made regarding optimal timing.

Level of Evidence

Level IV, systematic review of Level I through IV studies.

Biologic and synthetic ligament reconstructions achieve better functional scores compared to osteosynthesis in the treatment of acute acromioclavicular joint dislocation

PURPOSE

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

METHODS

Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of acute acromioclavicular joint dislocations were included. Following data were extracted: authors and year, study design, level of evidence, number of patients, age, classification of acromioclavicular joint dislocation, time to surgery, surgical technique, follow-up, clinical and imaging outcomes, complications, and failures. Descriptive statistics was used, when a data pooling was not possible. Comparable outcomes were pooled to generate summary outcomes reported as frequency-weighted values. Quality appraisal was assessed through the MINORS checklist.

RESULTS

One hundred and thirty-three studies were included for a total of 4473 shoulders. Mean age of participants was 36.9 years. Mean follow-up was 42.06 months. Arthroscopy showed better ASES (p < 0.0001) and lower VAS pain score (p = 0.0249) compared to an open approach. Biologic and synthetic reconstructions demonstrated better results over osteosynthesis techniques. Biologic techniques showed overall better Constant (p = 0.0001) and DASH (p = 0.0215) scores, while synthetic reconstruction showed better UCLA score (p = 0.0001). Among suture buttons, triple button showed overall better results in Constant (p = 0.0001) and VAS (p = 0.0001) scores, while better results in DASH score (p = 0.0003) were achieved by 2 double button techniques. Overall, the level of evidence was low.

CONCLUSION

Biological and synthetic reconstructions achieved better functional scores compared to osteosynthesis. Among suture buttons, the triple button showed better functional performance.

LEVEL OF EVIDENCE

IV.

TightRope vs Clavicular Hook Plate for Rockwood III-V Acromioclavicular Dislocations: A Meta-Analysis

Objective

To assess and compare the clinical outcomes and complications of TightRope® fixation vs hook plate fixation for the treatment of Rockwood III‐VI Acromioclavicular joint (ACJ) dislocations.

Methods

Relevant studies were identified by searching PubMed, Embase, and Web of Science databases, from their inception to 12 April, 2019. The main outcomes of interest included Constant Score, University of California Los Angeles (UCLA) Shoulder Score, Visual Analogue Scale (VAS), coracoclavicular distance (CCD), and complications. Weight mean difference (WMD) with 95% confidence intervals (95% CIs) or risk ratio (RR) with 95% CIs was used to calculate the data.

Results

Four studies with a total of 179 patients were included in this study. Compared with hook plate, TightRope® fixation was associated with a significantly less VAS score for pain (WMD = ‐0.69, 95% CI: −1.10, −0.27; P = 0.001). However, there were no significant differences between the two surgical techniques in terms of Constant Score (WMD = 6.12, 95% CI: −3.84, 16.08; P = 0.229), UCLA (WMD = 7.96, 95% CI: −5.76, 21.68; P = 0.256), CCD (WMD = 0.24, 95% CI: −0.67, 1.15; P = 0.602), and complication rate.

Conclusion

Both TightRope® and hook plate techniques offered effective outcomes in relieving the pain of dislocation and improving function of ACJ. However, TightRope® fixation showed an advantage over hook plate in terms of postoperative pain. Further larger‐scale RCTs are needed to verify our findings.

Does the ZipTightTM effective to maintain reduction after the treatment of acute acromioclavicular joint dislocation?

BACKGROUND

The present study evaluated the functional and radiographic outcomes of acute acromioclavicular (AC) joint reconstruction performed using the mini-open technique and a knotless suspensory loop device METHODS:: A total of 25 patients (20 male and 5 female patients; mean age, 30.7 years; standard deviation, 10 years; range, 17-57 years) who fulfilled the inclusion criteria were included in the study. A functional assessment was performed using the Constant and University of California Los Angeles score. The radiologic assessment included standard anterior-posterior views of the AC and coracoclavicular (CC) distances.

RESULTS

The mean follow-up period was 18.6 months (range, 12-23 months). The mean Constant score was 87.2 ± 3.2, and the mean University of California Los Angeles score was 30.1 ± 2.4 at the final follow-up. Radiological evaluation at the last follow-up of the patients: Although there was no statistically significant increase in the AC and CC values of the patients () at the last follow-up, the average CC value in 6 (24%) of the 25 patients was greater than 50% compared with the unaffected side CC and early postoperative CC values. However, there was no statistically significant difference in the Constant and UCLA scores between the 6 patients with reduction loss and the 19 patients with reduction maintenance (P = .86).

CONCLUSIONS

Clinical results of fixation of acute AC joint dislocations using the ZipTight knotless suspensory loop device system and mini-open technique were favorable in terms of functional recovery and pain relief. However, the major disadvantage of this method was radiological loss of AC joint reduction when compared to the contralateral shoulder.

Surgical treatment, complications, and reimbursement among patients with clavicle fracture and acromioclavicular dislocations: a US retrospective claims database analysis

Aims: To assess rates of surgical treatment, post-surgical complications, reoperations, and reimbursement in patients with clavicle fractures and acromioclavicular (AC) dislocations. Materials and methods: This US retrospective study used data from patients with ≥1 diagnosis of clavicle fracture or AC dislocation (index) between 2012-2016. Surgical treatment was defined as a procedure within 4 weeks after clavicle fracture/AC dislocation. Rates of complications (infection, non-union, mal-union), reoperations (device removal or revisions), and all-cause healthcare reimbursement (adjusted to 2016$) were evaluated 2 years post-index among surgical patients. Results: A total of 95,243 patients with clavicle fracture and 52,100 patients with AC dislocation were identified. Mean (SD) age for clavicle fracture and AC dislocation was 23.8 (18.6) and 33.0 (15.6) years, respectively. Most clavicle fracture and AC dislocation patients were male (70.9% and 78.0%, respectively), and had few comorbidities (86.4% and 84.8% had a Charlson Comorbidity Index = 0 and 73.1% and 66.0% had Elixhauser = 0, respectively). Only 15.2% of clavicle fracture and 5.3% of AC dislocation patients received surgical treatment. Among patients undergoing surgical treatment, 2-year rates of infection, non-union, and mal-union were 1.0%, 4.2%, and 0.9%, respectively, for clavicle fracture, and 2.0%, 0.9%, and 0.1%, respectively, for AC dislocation. Reoperations occurred in 83.0% of clavicle fracture and 67.5% of AC dislocation patients. Mean (SD) 2-year reimbursement was $27,635 ($68,173) for clavicle fracture and $23,096 ($28,746) for AC dislocation. Limitations: Administrative claims data lack clinical information, limiting inferences that can be made. This data may not be generalizable to other patients. Conclusions: Rates of surgical treatment for clavicle fractures and AC dislocation and rates of infection, non-union, and mal-union among surgically-treated patients were low. However, surgical patients had high rates of device removal or revision surgery during 2-year follow-up. Improved surgical methods and technologies could reduce non-planned reoperations and device removals, thereby reducing healthcare system costs.

Modified closed-loop double-endobutton technique for repair of rockwood type III acromioclavicular dislocation

Acromioclavicular dislocation (ACD) is a common injury. According to the Rockwood classification, ACD is classified into six types (type I–VI); however, for type III injuries, it remains controversial whether or not operative treatment should be applied. Numerous studies have advocated early surgical treatment to ensure early rehabilitation activities. Thus, the present study aimed to investigate a modified closed-loop double-endobutton technique (MCDT), that may be used to repair Rockwood type III ACD. In the current study, 61 patients with Rockwood type III ACD were enrolled during a period of 5 years at the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University. Patients were divided into three groups according to the surgical method used, the MCDT group (n=20), the common closed-loop double-endobutton technique (CCDT) group (n=21), and the clavicular hook plate fixation (CHPF) group (n=20). Preoperative and intraoperative information were recorded. Furthermore, the functional scores of injured shoulder were evaluated prior to surgery and following surgery with a 1-year follow-up. Among the three groups, postoperative functional scores were significantly more improved compared with those prior to surgery (P<0.05), and no significant difference was observed regarding the coracoclavicular interval with the 1-year follow-up (P>0.05). Postoperative functional scores in the MCDT and CCDT groups were significantly more improved compared those in the CHPF group (P<0.05). In addition, the duration of surgery in the MCDT group was significantly shorter compared with that in the CCDT group (P<0.05). Furthermore, compared with the CHPF group, the incision length was significantly shorter with reduced hemorrhage in the MCDT group (P<0.05). In conclusion, the results of the current study suggest that MCDT is more simple, convenient and efficient compared with CCDT, and is worth popularizing.