Minimally Invasive Coracoclavicular Ligament Reconstruction With a Flip-Button Technique (MINAR): Clinical and Radiological Midterm Results

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.

Minimally invasive reconstruction of acute acromioclavicular joint injuries using the TwinBridge button system

INTRODUCTION

Acute acromioclavicular joint (ACJ) injuries are among the most common shoulder injuries in active young adults. The most frequently used surgical treatments include the hook plate implantation and arthroscopic treatment using flip-button systems. The aim of this study was to evaluate the results of treating acute ACJ injuries using a new minimally invasive implant based on a flip-button system.

MATERIAL AND METHODS

From January 2016 to October 2019, a total of 20 patients with acute ACJ injuries (1 × Type III, 3 × Type IV, 16 × Type V) underwent surgery using the Twinbridge implant (Smith & Nephew). It is a prefabricated construct consisting of two Endobuttons connected with an UltraTape. One button is placed under the coracoid using a special aiming device and two buttons are placed on the clavicle. Preoperatively, 1 day postoperatively, 3 months and at least 1 year postoperatively, patients were clinically examined and bilateral stress view and axial radiographs were obtained. At final follow-up, the simple shoulder test (SST), Taft score, Constant score, and ACJ instability (ACJI) score were recorded and a side-to-side ratio of the coracoclavicular (CC) distance was calculated.

RESULTS

All 20 patients were contacted at final follow-up at a mean of 28 (min. 13, max 50) months. Six patients were not willing to come for a clinical and radiographic examination and were contacted via telephone. All six patients were free of complaints. Another two patients free of complaints refused radiographs at final follow-up. The patients presented a mean SST of 99.6% (20 patients, min. 91.7, max. 100), Taft score of 11.6/12 points (12 patients, min. 10, max. 12), ACJI of 85.5/90 points (12 patients, min. 78, max. 90), and a Constant score of 97.1 (14 patients, min. 81.0, max. 100) for the affected shoulder. Preoperative stress view images revealed a mean side-to-side difference of the CC distance with a ratio of 1:2.34 (min. 1:1.80, max. 1:3.33). At final follow-up, CC distance was calculated with a mean ratio of 1:1.12 (min. 1.1, max. 1:1.38). Axial images showed a proper position in all cases. A "perfect" radiological result was achieved in six patients (50%) with a side-to-side CC distance of less than 10% (ratio 1:1.1 or less). A Rockwood type II result was achieved in five patients (42%) with a distance of 10 to 25% (ratio 1.11-1.25). One (8%) presented with a Rockwood type III result with a difference of more than 25% (ratio 1:1.38) and was considered a radiological failure.

CONCLUSIONS

When used correctly, the Twinbridge implant offers good-to-excellent clinical and radiographic results using a minimally invasive surgical technique. Complication rate is comparable to other button-systems.

Surgical management of acute, high-grade acromioclavicular joint separations: a systematic review

Background

While a number of treatment options exist for repair of acute, high-grade acromioclavicular joint (ACJ) separation, none have emerged as the standard of care. The purpose of this study was to systematically review the literature on surgical treatment of acute, high-grade (Rockwood grades III-V) ACJ separations in order to compare outcomes between direct fixation and tendon graft ligament reconstruction.

Methods

A systematic review of the literature evaluating outcomes for acute ACJ separation treatment with direct fixation or free biologic tendon graft reconstruction was performed. The following databases were examined: the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2021), and Embase (1980-2021). Studies were included if they reported a mean time to surgery as <6 weeks, contained >10 patients with a minimum 1-year follow-up, and reported clinical or radiographic outcomes.

Results

A total of 52 studies met the inclusion criteria. Seven studies reported outcomes following tendon graft ligament reconstruction (n = 128 patients). There were multiple methods of direct fixation. Thirty-three studies utilized suture button constructs (n = 1138), 16 studies used hook plates (n = 567), 2 studies used coracoclavicular screws (n = 94), 2 studies used suture fixation (n = 93), 2 studies used suture anchor (n = 55), 2 studies used suture cerclage fixation (n = 87), 1 used single multistrand titanium cable (n = 24), and 1 used K wire (n = 11). The mean follow-up Constant scores ranged from 77.5 to 97.1 in the fixation group compared to 90.3-96.6 in the tendon graft group. The mean visual analog scale scores ranged from 0 to 4.5 in the fixation group and 0.1-1 in the tendon graft group. Net CC distance ranged from 17.5 to 3.6 mm in the fixation group and 7.4-4 mm in the tendon graft group. The revision rates ranged from 0.0% to 18.18% in the direct fixation group and 5.88%-17% in the tendon graft group.

Conclusion

Direct fixation and tendon graft reconstruction for management of acute, high-grade ACJ separations have similar patient subjective and radiographic outcomes, as well as complication and revision rates at a minimum 1-year follow-up.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Ligamentous healing potential of the acromioclavicular ligament following acute anatomical reconstruction

BACKGROUND

Horizontal instability following acute acromioclavicular joint (ACJ) reconstruction still occurs with a high prevalence. Although the human acromioclavicular ligament complex (ACLC) represents the major horizontal ACJ stabilizer, experimental studies on healing characteristics are lacking. Therefore, the purpose of this histological study was to investigate the healing potential of the ACLC following acute anatomical reconstruction METHODS: In this prospective clinical-experimental study, 28 ACLC biopsies were performed in patients with complete ACJ dislocations (Rockwood type 4 or 5) during acute hook plate stabilization (IG: implantation group; n = 14) and hook plate removal (EG: explantation group; n = 14). Histological analyses included Giemsa staining, polarized light microscopy and immunostaining against CD68, αSMA and collagen type I and type III. Histomorphological evaluation entailed cell counts, collagen expression score, ligament tissue maturity index (LTMI) and descriptive analysis of specific ligamentous structures. Statistics consisted of nonparametric Mann-Whitney U tests and a level of significance of P < .05.

RESULTS

Total cell counts (cells/mm² 1491 ± 296 vs. 635 ± 430; P < 0.001) and collagen III expression (3.22 ± 0.22 vs. 1.78 ± 0.41; P < 0.001) were higher in EG compared to IG. Inversely αSMA + (11 ± 9 vs. 179 ± 186; P < 0.001) and CD68 + cell counts (56 ± 20 vs. 100 ± 57; P 0.009) were significantly lower in the EG. The EG revealed a comparable reorientation of ligamentous structures. Consistently, ACLC samples of the EG (21.6 ± 2.4) displayed a high total but differently composed LTMI score (IG: 24.5 ± 1.2; P < 0.001).

CONCLUSIONS

This experimental study proved the ligamentous healing potential of the human ACLC following acute anatomical reconstruction. Histomorphologically, the ACLC reliably showed a ligamentous state of healing at a mean of about 12 weeks after surgery. However, processes of ligamentous remodeling were still evident. These experimental findings support recent clinical data showing superior horizontal ACJ stability with additional AC stabilization in the context of acute ACJ reconstruction. Though, prospective clinical and biomechanical studies are warranted to evaluate influencing factors on ACLC healing and potential impacts of acute ACLC repair on clinical outcome.

STUDY TYPE

Controlled Laboratory Study.

Comparison of clinical efficacy between arthroscopically assisted Tight-Rope technique and clavicular hook plate fixation in treating acute high-grade acromioclavicular joint separations

INTRODUCTION

The purpose of this study was to compare the results of arthroscopically assisted reduction of acute acromioclavicular (AC) joint separations with the Tight-Rope technique with results of clavicular hook plate fixation.

MATERIALS AND METHODS

The 28 patients with acute high-grade AC joint dislocation were treated with arthroscopic assisted fixation using the Tight-Rope system, the arthroscopic evaluation and treatment of glenohumeral lesions were performed before AC ligament reconstruction. Each Tight-Rope technique group patient was matched with three controls that underwent clavicular hook plate fixation, and preoperation and postoperative visual analogue scale (VAS) and functional recovery (Constant Score) of the shoulder joint was assessed,. Furthermore, the demographics and clinical characteristics were compared between the two groups.

RESULTS

All patients had clinical and radiological results available at 2 years or greater (mean: 34; range: 24-72 months), they were statistically significant improvement in the constant score and VAS score at the end of follow-up respectively (P < 0.001). Compared with the clavicular hook plate group, Tight-Rope system group patients were incurred significant statistically lower skin incision, hospitalization time and estimated blood loss (P < 0.001), and the constant score and VAS score at the end of follow-up was significantly higher in the Tight-Rope group (P < 0.001). Patients who underwent clavicular hook plate had a higher incidence of fixation failure [10 cases (11.9%) versus 2 cases (7.1%)] than those of the Tight-Rope system group.

CONCLUSIONS

The Tight-Rope technique is advantageous for treating these patients because it is a minimally invasive procedure with low complications and superior clinical outcomes.

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.

Mini open triple tunnel- double flip button techniques in treatment of acute acromioclavicular joint injuries: Case report

Acute acromioclavicular (AC) joint injuries are common and often occur in a contact sport activity. Most acute AC joint injuries surgery techniques focus on coracoclavicular (CC) ligament complex fixation; by single or double clavicle tunnel, but persisting vertical instability. In this paper, we introduce mini open triple tunnel- double flip button (TTDB) technique for acute AC joint dislocation by adding tunnel on clavicle to expand coverage of footprint of conoid and trapezoid ligament in order to improve vertical stability of the AC joint. This method is based on CC ligament augmentation with a double flip button/polydioxanone (PDS), combined with V-loop pulley suture for anatomical fixation. This is a prospective case report. Two professional, male basketball players in this study with a mean age of 25 years underwent surgery in 2019. Clinical subjective outcome, VAS score, Nottingham Clavicle Score, and radiological CC distance were measured before and after the operation. There were noticeable improvement in the patients' recovery after two years since the operation. We introduce TTDB technique as one of the open techniques for acute AC joint injuries in limited-resource hospital setting.

Rehabilitation Posture Does Not Affect the Outcome of Arthroscopically Treated Acromioclavicular Dislocation

PURPOSE

To assess the effect of the patient's posture (erect or supine) during rehabilitation sessions on pain, function, and the coracoclavicular (CC) distance after arthroscopic treatment of acromioclavicular joint dislocation.

METHODS

Sixty patients with acute type III or V acromioclavicular dislocation injuries were randomly allocated into 2 groups according to their posture during the rehabilitation phase: supine rehabilitation group (SRG) or erect rehabilitation group (ERG). Arthroscopic stabilization with a suspensory fixation device was used in all patients. The visual analog scale (VAS) score was assessed on the first postoperative day and at 1, 3, and 6 months postoperatively. The Constant-Murley score (CMS) was recorded preoperatively and at 3, 6, 12, and 24 months postoperatively. The CC distance was assessed preoperatively; on the first postoperative day; and at 6, 12, and 24 months postoperatively.

RESULTS

No significant differences were found between the 2 groups in terms of the VAS score, CMS, and CC distance changes. A significant improvement over the follow-up phase was identified in the VAS score and CMS in both groups. The CC distance in both groups was significantly reduced from preoperatively (29.34 mm in the ERG and 28.65 mm in the SRG) to the first postoperative day (10.44 mm and 10.11 mm, respectively). However, a statistically significant re-widening of the CC distance (P < .001) occurred within the first 6 months after surgery (13.55 mm in the ERG and 13.50 mm in the SRG) and at 12 months (15.51 mm and 15.80 mm, respectively).

CONCLUSIONS

The patient's posture during early postoperative rehabilitation does not affect the CC distance changes.

LEVEL OF EVIDENCE

Level I, randomized prospective comparative study.

Radiographic features and complications following coracoclavicular ligament reconstruction

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULT

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

CONCLUSION

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

The Relationship Between the Clinical and Radiological Findings and the Outcomes of Early Surgical Treatment After Tossy Type III Acromioclavicular Joint Dislocation

Background

Acromioclavicular joint (ACJ) dislocation is a common injury among young and physically active persons. Evaluating surgical outcomes clinically and radiographically is widely accepted, but it is not known which clinical tests or radiological indicators are the most important. Our hypothesis is that there is a significant correlation between clinical and radiological findings and outcomes after the early surgical treatment of Tossy type III ACJ dislocation. 

Materials and methods

A retrospective study was conducted on 23 patients who underwent early surgical treatment after Tossy type III ACJ dislocation. We used the constant score (CS) and the simple shoulder test (SST) to measure the outcomes. For clinical evaluation, Paxinos, O’Brien’s, Bell-van Riet’s, and horizontal adduction tests were used. Standard A-P view radiographs were evaluated for redislocation, ACJ arthrosis, coracoclavicular (CC) space ossification, and for the presence of osteolysis.

Results

The mean time of follow-up was 16 months (range, 12-22 months). During the follow-up, all patients had one or more pathological radiological signs. All clinical tests were negative in 12 patients, seven had one positive test, three had two positive tests, and one had three positive tests. The mean CS result at the follow-up was 93.44 ± 4.90 (range, 84-100), and the mean SST result was 10.78 ± 1.51 (range, 6-12). There was no statistically significant association between the CS results and either shoulder tests or radiological findings. The SST results were statistically significantly lower for patients with positive O’Brien’s test compared to those with a negative one. In contrast, the SST results were statistically significantly higher for patients with CC space ossification, compared to those who did not have this radiological sign. Other clinical tests and radiological findings did not have any associations with the SST results.

Conclusions

We found that positive O’Brien’s test was associated with worse outcomes of early surgical treatment after Tossy type III ACJ dislocation. Despite the presence of pathological radiological signs, patients may have good or even perfect clinical outcomes after the early surgical treatment of a Tossy type III injury.

Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tight rope: randomized comparative study of clinical outcome and cost-effectiveness

PURPOSE

The purpose of this study was to compare clinical outcome and cost-effectiveness between arthroscopic and open repair using TightRope in acromioclavicular joint dislocation III and IV.

PATIENTS AND METHODS

Fifty-two patients with acute acromioclavicular joint dislocation type III and IV were included. Patients were randomly allocated to either of 2 groups: Arthroscopic Repair Group (ARG) and Open Repair Group (ORG). Constant-Murley Score (CMS), visual analog scale (VAS) score, and coracoclavicular (CC) distance were measured preoperatively and 3 months, 6 months, 1 year, and 2 years postoperatively.

RESULTS

CMS increased from 40.68 for the ARG and 40.70 for the ORG preoperatively to 84.18 and 84.45 after 2 years from operation. VAS score decreased from 60.59 for the ARG and 64.50 for the ORG 1 day after surgery to 18.04 and 17.87 respectively after 6 months. CC distance decreased from 29.27 mm in the ARG and 28.16 mm in the ORG preoperatively to 9.86 mm in the ARG and 10.54 mm in the ORG on postoperative day 1. Rewidening of the CC distance occurred after 6 months (13.27 mm for the ARG and 13.62 mm for the ORG) and 1 year postoperatively (15.77 for the ARG and 15.41 for the ORG) but remained stable at final follow-up. There was a significant difference in surgical time (80.00 minutes in the ARG compared to 52.79 minutes in the ORG) and cost of consumables (US$1729.95 in the ARG compared to US$851.87 in the ORG).

CONCLUSION

Open and arthroscopic repair of acute acromioclavicular joint dislocation yielded good clinical results, yet the arthroscopic technique is more expensive and has a longer surgical time.

Minimally Invasive AC Joint Reconstruction System (MINAR®) in Modified Triple-Button Technique for the Treatment of Acute AC Joint Dislocation

Acute acromioclavicular (AC) joint dislocation is a frequent sports injury with more than 100 different operation methods described. A total of 65 patients with an acute AC joint dislocation were treated with the modified MINAR^® system between 2009 and 2013. Clinical outcome, horizontal and vertical instability, as well as concomitant intraarticular injuries were assessed. We used Zanca, stress and axial X-rays for radiological assessment. A Constant score of 95 (±8.8), University of California Los Angeles Shoulder score (UCLA) of 31 (±4.9), Disabilities of Arm, Shoulder and Hand (DASH) of 9.1 (±14.3), and Visual Analogue Scale (VAS) of 0.9 (±0.126) was found. A total of 30 patients (59%) had no signs of reduction loss, nine patients (18%) a slight loss, 11 patients (22%) a partial loss, and one patient (2%) a total loss. No significant influence on the clinical scores could be shown. The postoperative coracoclavicular (CC) distance negatively affected the Constant (p = 0.007) and UCLA scores (p = 0.035). A longer time interval to surgery had a negative influence on all scores (p ≤ 0.001). We could not find any signs of persistent horizontal instability or intraarticular injuries at follow-up. The MINAR^® system promises satisfactory functional and radiological results. When setting the correct indication, patients benefit from an early operation. No persisting horizontal instability was observed following suturing of the AC capsule and the delta fascia.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSION

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

All-Arthroscopic Reconstruction of Severe Chronic Acromioclavicular Joint Dislocations

PURPOSE

To report the outcomes of all-arthroscopic coracoclavicular (CC) ligament reconstruction and simultaneous diagnosis and treatment of glenohumeral pathologies in patients with symptomatic, chronic (>6 weeks), complete (Rockwood type III-V) acromioclavicular joint (ACJ) separations.

METHODS

We prospectively followed up 57 consecutive patients treated arthroscopically for chronic Rockwood type III (n = 11), type IV (n = 19), and type V (n = 27) ACJ dislocations. Previous ACJ surgery failed in 11 (19%). The mean delay between injury and surgery was 39 months (range, 6 months to 17 years). The mean age at surgery was 42 years (range, 19-71 years). After glenohumeral exploration, an arthroscopic modified Weaver-Dunn procedure with CC suture button fixation (Twinbridge) was performed. The CC reduction and tunnel position were analyzed with radiographs and computed tomography. The mean follow-up period was 36 months (range, 12-72 months).

RESULTS

Intra-articular pathology was treated arthroscopically in 27 patients (48%): 17 labral tears, 8 rotator cuff tears (3 partial and 5 complete), and 15 biceps lesions (4 SLAP lesions and 11 subluxations). At last follow-up, 7 patients (12%) experienced recurrent ACJ instability: 2 frank dislocations (1 trauma and 1 infection) and 5 ACJ subluxations. There was no significant correlation between subluxation and clinical outcome. The rate of recurrent ACJ instability was significantly higher in patients with higher-grade ACJ dislocations (P < .01) and/or previous failed surgery (P < .001). Recurrent subluxation was observed in 3 cases of lateral migration of the coracoid button with lateral tunnel placement, as well as 2 cases of anterior migration of the clavicular button with anterior tunnel placement. The Constant score increased from 67 (range, 28-89) to 85.5 (range, 66-100), and the mean Subjective Shoulder Value increased from 54% to 85% (P < .001). At last follow-up, 95% of patients (54 of 57) were satisfied.

CONCLUSIONS

All-arthroscopic treatment allows successful CC ligament reconstruction and simultaneous diagnosis and treatment of frequently associated (48%) glenohumeral lesions. Higher-grade ACJ dislocations, previous ACJ surgery, and misplacement of bone tunnels are risk factors for recurrent instability.

LEVEL OF EVIDENCE

Level IV, case series.

Challenges in Treating Acromioclavicular Separations: Current Concepts

Injuries to the acromioclavicular joint constitute approximately 3.2% of shoulder injuries. Although the overall goal of treatment continues to be return to activity with a pain-free shoulder, the treatment of acromioclavicular joint separations has been fraught with conflict since the earliest reports in both ancient and modern literature. Accurate diagnosis and classification are important to determine the optimal treatment. Nonsurgical therapy remains the mainstay for treatment of low- and most mid-grade injuries, although recent biomechanical and biokinetic data might suggest that patients are more affected than traditionally thought. High-grade injuries often necessitate surgical intervention, although little consensus exists on the timing or technique. New surgical techniques continue to evolve as more biomechanical data emerge and kinematic understanding improves. Challenges associated with management of this injury abound from diagnosis to reconstruction.

Arthroscopic treatment of acromioclavicular dislocation

A thorough understanding of biomechanical function of both acromioclavicular (AC) and coracoclavicular (CC) ligaments, stimulated surgeons to repair high-grade AC dislocation using arthroscopic technique. This technique necessitates a clear understanding of shoulder anatomy, especially of the structures in proximity to the clavicle and coracoid process and experiences in arthroscopic surgery. The follow case describes an arthroscopic technique used to treat AC dislocation in young man 30 years old, who suffered an injury at right shoulder. Results were similar to those obtained using open surgery and this encouraged us to continue utilization of this method. As a conclusion, arthroscopic treatment of AC separation is one of the best options as surgical treatment. Early results suggested that immediate anatomic reduction of an acute AC separation usually provides satisfactory clinical results at intermediate-term follow-up.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

A Novel Surgical Technique for Fixation of Recurrent Acromioclavicular Dislocations: AC Dog Bone Technique in Combination with Autogenous Semitendinosus Tendon Graft

Various surgical techniques have been described for the fixation of acromioclavicular (AC) dislocations. However, recurrent dislocation is one of the main complications associated with the majority of these techniques. We report a case of postoperative AC joint redislocation. In order to overcome recurrent dislocation after revision surgery, a reconstruction of the conoid and trapezoid ligament with the use of a free tendon graft in combination with a FiberTape was provided within a novel surgical technique. After 12 months, the patient was very satisfied with the functional outcome. The patient achieved excellent results in the Constant (98 points), SPADI (0 points), and QuickDASH score (0 points). The described technique results in an anatomic reconstruction of the AC joint. The nonrigid nature of the intervention seems to restore the normal arthrokinematics by reconstructing the coracoclavicular ligaments with an autograft which is then protected by the AC Dog Bone artificial ligaments during the healing period. The arthroscopic approach to the AC joint with minimal exposure reduces the risks and complications of the intervention. This is the first case in literature that utilizes the artificial dog bone ligament securing the autograft in an anatomic AC reconstruction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Acromioclavicular Joint Reconstruction Using Knotless Coracoclavicular Fixation and Soft-Tissue Anatomic Coracoclavicular Ligament Reconstruction

Acromioclavicular joint injuries are one of the most common shoulder injuries, and there are a variety of treatment options. Recently, there have been newer arthroscopic techniques that have addressed coracoid and clavicle fracture risk by using a knotted suture-button fixation through a single, small bone tunnel with additional looped soft-tissue graft stabilization. Although clinical outcomes have been good to excellent, there have still been instances of knot and hardware irritation. The described technique builds on the latest advances and achieves an anatomic coracoclavicular (CC) reconstruction through a single knotless CC fixation device with additional soft-tissue allograft reconstruction of the CC ligaments. This technique minimizes the risks of coracoid and clavicle fractures and knot and hardware irritation while maintaining excellent stability.

Biomechanical Analysis of Intra-articular Pressure After Coracoclavicular Reconstruction

BACKGROUND

Recent biomechanical and clinical studies have demonstrated the effectiveness of suture button and pulley-type fixations for surgical treatment of acromioclavicular instability. Concerns remain that such procedures can "overconstrain" (overreduce the lateral clavicle in relation to the acromion to a nonphysiological position) the joint. Purpose/Hypothesis: The purpose of this study was to investigate the intra-articular pressure of native and reconstructed acromioclavicular (AC) joints in relation to the configuration of the joint. Anatomic (0 mm), overconstrained (-3 mm), and underconstrained (+3 mm) AC joint reconstructions were simulated. The hypothesis was that reconstructions using suture pulley systems do not increase the intra-articular pressure of the AC joint.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eleven fresh-frozen cadaveric shoulders were used in this study (mean age ± SD, 60.8 ± 6.7 years). Each specimen underwent radiographic analysis by using a Zanca view to determine the basic configuration of the AC joint. A pressure Tekscan sensor was inserted in the AC joint. A servohydraulic materials testing system was used for testing. The specimens were kept in the testing machine, and the native AC position was marked at 0 mm. This allowed moving the clavicle during the surgical procedure with reference to the native anatomic position. Intra-articular pressure in the native AC joint during cyclic loading (1000 cycles; 1 Hz) was measured. After native testing, the AC ligaments and coracoclavicular ligaments were cut and reconstructed using a cortical button technique. Anatomic, -3 mm, and +3 mm positions, relative to the acromion, were cyclically loaded, and intra-articular pressure was documented.

RESULTS

According to the AC joint classification of inclination, we identified five type 1 (46%), four type 2 (36%), one type 3 (9%), and one incongruous (9%) configurations. Changes in superior displacement across the 4 conditions were not statistically significant (0.5 ± 0.8 [native], 0.01 ± 0.00 [0 mm repair], 0.02 ± 0.02 [-3 mm repair], and 0.01 ± 0.01 [+3 mm repair]; P = .162). Before testing (time point 1), pressure in the -3 mm repair (62.9 ± 70.1) differed between the native state (11.3 ± 21.8; P = .042) and the +3 mm repair (7.1 ± 18.4; P = .023). All other changes at time points 2 (after cyclic loading unloaded) and 3 (after cyclic loading loaded) in pressure were not significant. ( P = .086 and .226, respectively).

CONCLUSION

AC joint reconstruction (within -3 to +3 mm of reduction) with a coracoclavicular suture button device does not significantly increase the intra-articular pressure of the AC joint after cyclic loading in our experimental cadaveric setup.

CLINICAL RELEVANCE

Recent biomechanical and clinical studies have demonstrated the effectiveness of suture button and pulley-type fixations for coracoclavicular reconstruction of the joint. Concerns remain that such procedures would "overconstrain" the joint because of the high rigidity of these pulley systems and the preservation of the lateral clavicle. This overconstraining may potentially result in pain at the lateral end of the clavicle, osteolysis, or a later increased risk of early osteoarthritis. Therefore, our results indicate that within a range of ±3 mm to the anatomic position, overconstraining may not result in a higher intra-articular pressure.

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

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

Acute high-grade acromioclavicular dislocations treated with triple button device (MINAR): Preliminary results

OBJECTIVE

Describe the clinical and radiological results of triple button device in the treatment of high-grade AC dislocations (Rockwood, type V) and assess whether improves vertical and horizontal stability compared to the techniques previously described.

MATERIAL AND METHODS

This retrospective study included 39 patients with type V acromioclavicular dislocations treated with Twin Tail TightRope™ system (triple button device). Of the 39 patients, 33 (26 men and 7 women) were able to participate in clinical and radiographic follow up. At the time of surgery, the mean age was 25years±7(range, 17-49). All patients underwent bilateral-weighted Zanca (CC distance) and Alexander view (AC distance) as well as the Constant Score (CS) and Acromioclavicular Joint Instability Scoring System (ACJI). Radiological and clinical outcome was assessed during routine follow-up examinations preoperatively, postoperatively, 1, 3, 6 months and every year after the surgery. The presence of calcification, degenerative changes, mobilization of implants and bone resorption were also assessed.

RESULTS

After a mean follow up of 25±4months (range 14-38), the results of the Constant (CS) were 94.1±5,5 (range 76-100) and test ACJI 87.3±9,8 (range 65-100), showing no significant differences with the uninjured shoulder (CS 95.8±2.5, range 83-100; ACJI 94.1±3.7, range 80-100). At final review, we observed that preoperative coracoclavicular distance (Zanca View) improved from 21,75±1.97mm to 8,73mm±0.75 and the acromioclavicular distance (Alexander View) from 12,65mm±1.99 to 0,35±0.3mm. Compared with healthy shoulder, these differences were not significant. There was no loss of reduction with this system in the vertical plane. 4 patients (12.12%) revealed signs of posterior instability with worse clinical test results. The presence of degenerative joint changes (6,06%), calcifications (27,2%) or mobilization of the implant (18,18%) was not associated with worse clinical outcomes.

CONCLUSION

Twin Tail device using minimally invasive technique improves stability in the vertical and, specially in the horizontal plane relative to the previously described techniques without increasing number of complications.

Injury patterns of the acromioclavicular ligament complex in acute acromioclavicular joint dislocations: a cross-sectional, fundamental study

BACKGROUND

Horizontal instability impairs clinical outcome following acute acromioclavicular joint (ACJ) reconstruction and may be caused by insufficient healing of the superior acromioclavicular ligament complex (ACLC). However, characteristics of acute ACLC injuries are poorly understood so far. Purposes of this study were to identify different ACLC tear types, assess type-specific prevalence and determine influencing cofactors.

METHODS

This prospective, cross-sectional study comprised 65 patients with acute-traumatic Rockwood-5 (n = 57) and Rockwood-4 (n = 8) injuries treated operatively by means of mini-open ACJ reduction and hook plate stabilization. Mean age at surgery was 38.2 years (range, 19-57 years). Standardized pre- and intraoperative evaluation included assessment of ACLC tear patterns and cofactors related to the articular disc, the deltoid-trapezoidal (DT) fascia and bony ACJ morphology. Articular disc size was quantified as 0 = absent, 1 = remnant, 2 = meniscoid and 3 = complete.

RESULTS

All patients showed complete ruptures of the superior ACLC, which could be assigned to four different tear patterns. Clavicular-sided (AC-1) tears were observed in 46/65 (70.8 %), oblique (AC-2) tears in 12/65 (18.5 %), midportion (AC-3) tears in 3/65 (4.6 %) and acromial-sided (AC-4) tears in 4/65 (6.1 %) of cases. Articular disc size manifestation was significantly (P < .001) more pronounced in patients with AC-1 tears (1.89 ± 0.57) compared to patients with AC-2 tears (0.67 ± 0.89). Other cofactors did not influence ACLC tear patterns. ACLC dislocation with incarceration caused mechanical impediment to anatomical ACJ reduction in 14/65 (21.5 %) of cases including all Rockwood-4 dislocations. Avulsion "in continuity" was a consistent mode of failure of the DT fascia. Type-specific operative strategies enabled anatomical ACLC repair of all observed tear types.

CONCLUSIONS

Acute ACLC injuries follow distinct tear patterns. There exist clavicular-sided (AC-1), oblique (AC-2), midportion (AC-3) and acromial-sided (AC-4) tears. Articular disc size was a determinant factor of ACLC tear morphology. Mini-open surgery was required in Rockwood-4 and a relevant proportion of Rockwood-5 dislocations to achieve both anatomical ACLC and ACJ reduction. Type-specific operative repair of acute ACLC tears might promote biological healing and lower rates of horizontal ACJ instability following acute ACJ reconstruction.

PREFERED SURGICAL TECHNIQUE USED BY ORTHOPEDISTS IN ACUTE ACROMIOCLAVICULAR DISLOCATION

Objective:

To determine whether training on shoulder and elbow surgery influences the orthopedist surgeons' preferred technique to address acute acromioclavicular joint dislocation (ACD).

Methods:

A survey was conducted with shoulder and elbow specialists and general orthopedists on their preferred technique to address acute ACD.

Results:

Thirty specialists and forty-five general orthopedists joined the study. Most specialists preferred the endobutton technique, while most general orthopedists preferred the modified Phemister procedure for coracoclavicular ligament repair using anchors. We found no difference between specialists and general orthopedists in the number of tunnels used to repair the coracoclavicular ligament; preferred method for wire insertion through the clavicular tunnels; buried versus unburied Kirschner wire insertion for acromioclavicular temporary fixation; and time for its removal; and regarding the suture thread used for deltotrapezoidal fascia closure.

Conclusion:

Training on shoulder and elbow surgery influences the surgeons' preferred technique to address acute ACD. Level of Evidence V, Expert Opinion.

A Biomechanical Analysis of Different Clavicular Tunnel Diameters in Anatomic Acromioclavicular Ligament Reconstruction

PURPOSE

To evaluate the biomechanical stability of a tendon-to-clavicle bone interface fixation of a graft in revision acromioclavicular reconstruction.

METHODS

Fifteen fresh-frozen cadaveric shoulders were used. All specimens underwent bone density evaluation. For the primary reconstruction, a 5-mm semitendinosus allograft was inserted into a 5-mm bone tunnel at 25 and 45 mm from the lateral end of the clavicle using a 5.5 × 8-mm PEEK (polyether ether ketone) tenodesis screw. Each single graft was fixed in a cryo-clamp and cyclically loaded from 5 to 70 N for 3,000 cycles, followed by load-to-failure testing at a rate of 120 mm/min to simulate the revision case. To simulate tunnel widening, the tunnels of the revision series were over-drilled with an 8-mm drill, and a 5-mm semitendinosus graft with an 8 × 12-mm PEEK tenodesis screw was inserted. Biomechanical testing was then repeated.

RESULTS

The bone mineral density analysis showed a significantly higher density at the 45-mm hole compared with the 25-mm hole (P = .001). The ultimate load to failure increased from the 5.5-mm screw to the 8-mm screw at the 45-mm hole position (P = .001). There was no statistically significant difference at the 25-mm hole position (P = .934). No statistical significance for graft elongation comparing the 5.5-mm screw and the 8-mm screw at the 25-mm (P = .156) and 45-mm (P = .334) positions could be found.

CONCLUSIONS

Comparable biomechanical stability for the tendon-to-bone interface fixation in different clavicular tunnel diameters simulating primary and revision reconstruction was achieved.

CLINICAL RELEVANCE

There is a lack of literature regarding revision acromioclavicular joint reconstruction, but our biomechanical results show comparable stability to primary reconstruction. These data provide support for the use of anatomic acromioclavicular ligament reconstruction in revision cases.

Comparing mini-open and arthroscopic acromioclavicular joint repair: functional results and return to sport

INTRODUCTION

Acromioclavicular joint (ACJ) dislocation is a common injury that can result from sports activities. The surgical technique for the treatment of Type III and Type IV injuries, according to the Rockwood classification, remains controversial. The purpose of the study was to determine the functional outcome after minimally invasive and arthroscopic surgery. The mini-open surgery was done with MINAR^® system, whereas the arthroscopic technique was done with Dog Bone^TM Button.

STUDY DESIGN

Retrospective Cohort study.

METHODS

We reviewed 31 who were surgically treated for acute acromioclavicular dislocation Type III and Type IV (2012-2015). We excluded subjects with chronic dislocation or other injury. We selected 16 patients (average age 37).  Half of the sample patients were treated with mini-open surgery with the MINAR^® system, and the other half of the patients were treated with the Dog Bone arthroscopic technique. The Constant Shoulder Score, the Oxford Shoulder Score, the Simple Shoulder Test and the Subjective Patient Outcome for Return to Sports (SPORTS) score were used to assess functional outcome of the treated shoulder.

RESULTS

Mean follow-up was 13 months (range 6-27 months). The mean Constant Shoulder Score was 91.10 (range 82.76-96.66), Oxford Shoulder Score was 46.19 (range 42.00-48.00), the Simple Shoulder Test was 10.50 (range 9.00-12.00), and the SPORTS score was 7.88 (range 3-10). There is a statistically significant difference between the sample operated with the mini-open surgery and the group operated with arthroscopic technique. The probability of return to their sport, according to the results of the SPORTS score, was significantly higher for patients treated with the MINAR^® system (p < 0.001). However, the objective parameter of Constant scale is statistically better in patients operated by arthroscopic technique (p < 0.05; p < 0.001).

CONCLUSION

Restoration of ACJ anatomy is the key to a successful therapy. The surgical technique should be personalized. The miny-open surgery and also the arthroscopic surgery are adequate with good clinical results. However, according to the SPORTS score, the patients treated with mini-open surgery returned to their sport with less pain and better performance than those belonging to the other group.