Treatment of AC dislocation by reconstructing CC and AC ligaments with allogenic tendons compared with hook plates

Comparison of Effectiveness and Safety in Treating Acute Acromioclavicular Joint Dislocation with Five Different Surgical Procedures: A Systematic Review and Network Meta-Analysis

This network meta-analysis aims to evaluate the comparative effectiveness and safety of suture anchors (SA), tendon grafts (TG), hook plates (HP), Tight-Rope (TR), and EndoButton (EB) in the treatment of acute acromioclavicular joint (ACJ) dislocation. The Embase, PubMed, and Web of Science databases were searched from their inception date to June 3, 2022. Studies included all eligible randomized controlled trials (RCTs) and cohort studies with the comparison of five different fixation systems among SA, TG, HP, TR, and EB were identified. All studies were reviewed, performed data extraction, and assessed the risk of bias independently by two reviewers. The primary outcomes are Constant-Murley score (CMS) improvement for assessing clinical efficacy, and complications. The second outcomes are visual analog scale (VAS) for assessing pain relief and the coracoclavicular distance (CCD) for assessing postoperative joint reduction. Version 2 of the revised Cochrane risk of bias tool for randomized trials (RoB 2) and the risk of bias in nonrandomized studies of interventions (ROBINS-I) were used to assess the RCTs and non-randomized trials, respectively. The continuous outcomes were presented as mean differences (MD), and risk ratios (OR) were used for dichotomous outcomes, both with 95% confidence intervals (CI). Surface under the cumulative ranking curves (SUCRA) results were calculated to offer a ranking of each intervention. We identified 31 eligible trials, including 1687 patients in total. HP showed less CMS improvement than TR and EB in both the Network Meta-analysis (NMA) and pairwise meta-analysis. HP also showed less CMS improvement than SA in NMA. For pain relief, HP performed worse than TR both in pairwise meta-analysis and NMA. No significant differences were found for the measured value of CCD. Both TR and EB showed a lower incidence of complications than HP in pairwise meta-analysis. The rank of SUCRA for CMS improvement was as follows: SA, TR, EB, TG, and HP; for pain relief: TR, EB, TG, SA, and HP; for CCD: HP, TR, SA, EB, and TG. For complications, HP showed the highest rank, followed by TG, EB, TR, and SA. SA shows better clinical effectiveness and reliable safety in the treatment of acute ACJ dislocation. Although HP is the most widely used surgical option currently, it should be carefully taken into consideration for its high incidence of complications.

Anatomical acromioclavicular joint stabilization with chemically sterilized tendon allografts: A retrospective study

Background

The purpose of this retrospective study was to analyze whether chemically sterilized tendon allografts perform as well as other non-sterilized allografts and autografts as described in the literature for anatomical acromioclavicular joint stabilization for the treatment of Rockwood III-V. Allografts are still described as a factor for higher re-rupture rates.

Methods

Retrospective data were collected from 21 acromioclavicular joint stabilizations performed by a single surgeon and performed between 2011 and 2014 using sterilized semitendinosus allografts. The primary endpoints were re-rupture and complication rates. Secondary endpoints were AC-joint stability, pain level, return to work and sport and the range of motion.

Results

No re-ruptures occurred during the mean follow-up time of 33 months. Zero complications occurred directly after surgery, but three complications later than three weeks after surgery. All cases resolved without further surgery. After surgery, stability significantly improved for all patients. Post-surgery, 19 patients had stable acromioclavicular joints and only two patients showed minor instabilities. Range of motion returned to the range of the healthy shoulders for all patients.

Conclusion

Chemically sterilized semitendinosus allograft use for anatomic AC-joint stabilization is equivalent to the use of other allografts or autografts and required no hardware removal. No donor age or graft size dependence was observed, due to zero re-ruptures.

Atraumatic Acromioclavicular Joint Dislocation: A Case Report Treated with Excision of the Distal Clavicle Margin and Button Slide System with Allograft Tendon Reinforcement at Coracoclavicular and Acromioclavicular Joint

Although acromioclavicular joint (ACJ) dislocation is a common injury following trauma involving the shoulder, it is rare in the absence of trauma. In this manuscript, we describe a case of ACJ in a 15-year-old girl who presented a painful dislocation with spontaneous shortening of the right acromioclavicular joint that forced her to temporarily abandon her sports career. After failure of conservative physiotherapy treatment, surgical intervention was proposed by performing an arthroscopic-assisted button slide combined with augmented hamstring allograft reconstruction. After the intervention and the subsequent recovery period, the athlete was able to return to her semi-professional training. The follow-up of the patient is 5.5 years post-surgery. The result obtained could help in planning the treatment of future cases.

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.

Criteria for return to play after operative management of acromioclavicular joint separation: a systematic review

Background

Acromioclavicular (AC) joint separation is a common cause of shoulder injury among athletes. High-grade injuries may require operative fixation, and comprehensive return-to-play guidelines have not yet been established. The purpose of this study was to summarize criteria for return to play after operative management of AC joint separation.

Methods

A systematic review of the literature was performed from January 1999 to April 2020 to evaluate clinical evidence regarding criteria for return to play after operative management of isolated AC joint separation.

Results

Sixty-three studies with at least 1 explicitly stated return-to-play criterion were identified out of an initial database search of 1253 published articles. Eight separate categories of return-to-play criteria were identified, the most common of which was time from surgery (95.2%). Return-to-play timelines ranged from 2 to 12 months, the most common timeline being 6 months (37.8%). Only 4 (6.3%) studies used conditional criteria to guide return to play, which included range of motion, strength, clinical stability, radiographic stability, functional assessment, safety assessment, and hardware removal.

Conclusion

Most published studies use only time-based criteria for return to play after surgery for AC joint separation, and only a small number of studies use additional subjective or objective criteria. While this systematic review helps provide a foundation for developing a comprehensive return-to-play checklist, further investigation is needed to establish safe and effective guidelines that will enable athletes to safely return to sport and minimize the recurrence of injury.

Does coracoclavicular augmentation additional to hook plate fixation provide benefits in acute unstable acromioclavicular dislocation? A meta-analysis

Background

Acromioclavicular joint (ACJ) dislocation is a common shoulder injury. In treating acute unstable ACJ dislocation, a hook plate (HP) is a straightforward and popular option for ensuring proper reduction and rigid fixation while promoting AC and coracoclavicular (CC) ligament healing. Surgeons typically remove the HP to prevent subacromial impingement and acromial osteolysis; however, concerns about redislocation after implant removal remain. Therefore, additional CC augmentation may be helpful in combination with HP fixation. The aim of this meta-analysis is to compare the outcomes and complications of HP fixation with or without additional CC augmentation for acute unstable ACJ dislocation.

Methods

We searched the PubMed, EMBASE, and Web of Science databases for relevant case–control studies. The primary outcomes were patient-reported outcome measures; the secondary outcomes were pain measured using a visual analog scale (VAS), CC distance (CCD), and complications. Continuous data were assessed using weighted standardized mean differences (SMDs) with 95% confidence intervals (CIs), and dichotomous data were evaluated with Mantel–Haenszel odds ratio (ORs) with 95% CIs.

Results

We analyzed one randomized control trial and four case–control studies comparing HP fixation with or without CC augmentation. A total of 474 patients with Rockwood type III or V ACJ dislocation were included. We found no differences in Constant–Murley score (SMD, − 0.58, 95% CI − 1.41 to 0.26; P = 0.18), American Shoulder and Elbow Surgeons score (SMD, 0.21, 95% CI − 0.10 to 0.52; P = 0.19), University of California at Los Angeles shoulder rating scale score (SMD, − 0.02, 95% CI − 1.27 to 1.23; P = 0.97), or VAS pain score (SMD, 0.36, 95% CI − 0.16 to 0.88; P = 0.17) between groups. The CC augmentation group had lower odds of osteolysis (OR, 0.27, 95% CI 0.10 to 0.74; P = 0.01) and a shorter CCD (SMD, − 0.29, 95% CI − 0.57 to − 0.01; P = 0.04).

Conclusion

HP fixation with CC augmentation is preferable for acute unstable ACJ dislocations. Although CC augmentation did not provide additional benefits related to functional outcomes or pain, it resulted in greater reduction maintenance after implant removal and a 73% lower risk of acromial osteolysis.

Trial registration

PROSPERO (CRD42021271118).

Does Weaver-Dunn procedure have a role in chronic acromioclavicular dislocations? A meta-analysis

Background

In treatment of chronic acromioclavicular (AC) joint dislocations, both the Weaver–Dunn procedure (WD) and CC ligament reconstruction (CCR) are recommended options due to the low possibility of healing of the coracoclavicular (CC) ligaments. The aim of this review was to determine whether CCR will yield favorable clinical and radiographic outcomes in the treatment of chronic AC dislocations.

Method

The Cochrane Library, EMBASE, and PubMed databases were searched for literature on chronic AC dislocations from data inception to June 30, 2021. Patient data were pooled using standard meta-analytic approaches. The Cochrane-Mantel–Haenszel method and variance-weighted means were used to analyze the outcomes. The Review Manager version 5.3 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) was used to calculate the heterogenicity, mean difference, and relative risk (RR) for all outcomes in the meta-analysis.

Results

The current analysis included four trials on this topic, and all AC joint dislocations were classified as Rockwood types III to VI. The pooled data showed that the CCR group had significantly better post-operative American Shoulder and Elbow Surgeons Shoulder (ASES) scores, Oxford Shoulder Scores (OSSs), and Nottingham Clavicle Scores (NCSs) than the WD group, with a significant difference (p < 0.001, p = 0.020, and p < 0.001, respectively). In terms of the post-operative Constant-Murley Scores (CMSs), there were no significant differences between the CCR group and the WD group (p = 0.100). The CCR group had significantly better post-operative abduction and flexion of the index shoulder than the WD group (p < 0.001 and p < 0.001, respectively). In terms of radiological outcomes, the post-operative coracoclavicular distance (CCD) with a 10 kg load was smaller in the CCR group compared to that in the WD group (p < 0.001). The overall surgical wound infection rate was 11.6% in the WD group and 12.9% in the CCR, respectively (p = 0.82).

Conclusion

The CCR group had better clinical outcome scores in the ASES, OOS, NCS, abduction, flexion, and external rotation than the WD group. In terms of radiological outcomes, the CCR group showed less displacement in weight-loaded post-CCD than the WD group, which indicated that the CCR provided more stability and resistance to deformation forces.

Anatomic reconstruction of the acromioclavicular joint provides the best functional outcomes in the treatment of chronic instability

PURPOSE

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

METHODS

Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of chronic 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

Fourty-four studies were included for a total of 1020 shoulders. Mean age of participants was 38 years. Mean follow-up was 32.9 months. Arthroscopic techniques showed better results than open approach (p < 0.0001). Synthetic reconstructions demonstrated better functional outcomes compared to internal fixation and biologic techniques (p < 0.0001). Among biologic techniques, combined coracoclavicular and acromioclavicular ligaments reconstruction showed better Constant (p = 0.0270) and ASES (p = 0.0113) scores compared to isolated coracoclavicular ligaments reconstruction; anatomic biologic non-augmented graft reconstruction showed better Constant (p < 0.0001), VAS (p < 0.0001) and SSV (p = 0.0177) results compared to augmented techniques. No differences in functional outcomes could be found between anatomic biologic non-augmented graft versus synthetic reconstructions. Overall, methodological quality of the included studies was low.

CONCLUSION

Anatomic reconstructions, both synthetic and biologic, showed the best functional results.

LEVEL OF EVIDENCE

IV.

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.

Rockwood Grade-III Acromioclavicular Joint Separation: A Cost-Effectiveness Analysis of Treatment Options

Background:

The treatment of Rockwood Grade-III acromioclavicular (AC) joint separation has been widely disputed since the introduction of the classification system. The present literature does not reach consensus on whether operative or nonoperative management is more advantageous, nor does it effectively distinguish between operative measures. We hypothesized that nonoperative treatment of Rockwood Grade-III AC joint separation would be more cost-effective when compared with surgical options.

Methods:

We created a decision-tree model outlining the treatment of Rockwood Grade-III separations using nonoperative management or hook-plate, suture-button, or allograft fixation. After nonoperative intervention, the possible outcomes predicted by the model were uneventful healing, delayed operative management, a second round of sling use and physical therapy, or no reduction and no action; and after operative intervention, the possible outcomes were uneventful healing, loss of reduction and revision, and depending on the implant, loss of reduction and no action, or removal of the implant. A systematic review was conducted, and probabilities of each model state were averaged. A cost-effectiveness analysis was conducted both through rollback analysis yielding net monetary benefit and through incremental cost-effectiveness ratios (ICERs). Thresholds of $50,000/quality-adjusted life-year (QALY) and $100,000/QALY were used for ICER analysis. Furthermore, a sensitivity analysis was utilized to determine whether differential probabilities could impact the model.

Results:

Forty-five papers were selected from a potential 768 papers identified through our literature review. Nonoperative treatment was used as our reference case and showed dominance over all 3 of the operative measures at both the $50,000 and $100,000 ICER thresholds. Nonoperative treatment also showed the greatest net monetary benefit. Nonoperative management yielded the lowest total cost ($6,060) and greatest utility (0.95 QALY). Sensitivity analysis showed that allograft fixation became the favored technique at a willingness-to-pay threshold of $50,000 if the rate of failure of nonoperative treatment rose to 14.6%. Similarly, at the $100,000 threshold, allograft became dominant if the probability of failure of nonoperative treatment rose to 22.8%.

Conclusions:

The cost-effectiveness of nonoperative treatment is fueled by its notably lower costs and overall high rates of success in Grade-III separations. It is important to note that, in our analysis, the societal cost (measured in lost productivity) of nonoperative treatment neared that of surgical treatment, but the cost from the health-care system perspective was minimal. Physicians should bear in mind the sensitivity of these conclusions and should consider cost-effectiveness analyses in their decision-making guidelines.

Level of Evidence:

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Editorial Commentary: Suture Button-Anchor Fixation Is Preferable to Hook Plate Fixation for Acute Acromioclavicular Joint Dislocations: Form and Function Need to Be United

Both hook plate fixation and suture button-anchor fixation have been reported to yield good results in the treatment of acute acromioclavicular joint reconstruction. In addition to a mandatory secondary procedure, hook plate fixation clearly has an increased prevalence of post-traumatic acromioclavicular arthritis in the short term that is likely to progress in the long term. Conversely, suture button-anchor fixation-a minimally invasive technique that creates less soft-tissue disruption, does not require hardware removal, and does not violate the acromioclavicular joint-is more likely to promote primary healing of the coracoclavicular ligaments, reduce the risk of late displacement, and minimize the development of post-traumatic acromioclavicular arthritis. As stated by the noted architect Frank Lloyd Wright, it is not only about form (i.e., alignment), it is about function as well.

Quantitative and Qualitative Surgical Anatomy of the Acromioclavicular Joint Capsule and Ligament: A Cadaveric Study

BACKGROUND

The acromioclavicular (AC) capsule and ligament have been found to play a major role in maintaining horizontal stability. To reconstruct the AC capsule and ligament, precise knowledge of their anatomy is essential.

PURPOSE/HYPOTHESIS

The purposes of this study were (1) to determine the angle of the posterosuperior ligament in regard to the axis of the clavicle, (2) to determine the width of the attachment (footprint) of the AC capsule and ligament on the acromion and clavicle, (3) to determine the distance to the AC capsule from the cartilage border of the acromion and clavicle, and (4) to develop a clockface model of the insertion of the posterosuperior ligament on the acromion and clavicle. It was hypothesized that consistent angles, attachment areas, distances, and insertion sites would be identified.

STUDY DESIGN

Descriptive laboratory study.

METHODS

A total of 12 fresh-frozen shoulders were used (mean age, 55 years [range, 41-64 years]). All soft tissue was removed, leaving only the AC capsule and ligament intact. After a qualitative inspection, a quantitative assessment was performed. The AC joint was fixed in an anatomic position, and the attachment angle of the posterosuperior ligament was measured using a digital protractor. The capsule and ligament were removed, and a coordinate measuring device was utilized to assess the width of the AC capsule footprint and the distance from the footprint to the cartilage border of the acromion and clavicle. The AC joint was then disarticulated, and the previously marked posterosuperior ligament insertion was transferred into a clockface model. The mean values across the 12 specimens were demonstrated with 95% CIs.

RESULTS

The mean attachment angle of the posterosuperior ligament was 51.4° (95% CI, 45.2°-57.6°) in relation to the long axis of the entire clavicle and 41.5° (95% CI, 33.8°-49.1°) in relation to the long axis of the distal third of the clavicle. The mean clavicular footprint width of the AC capsule was 6.4 mm (95% CI, 5.8-6.9 mm) at the superior clavicle and 4.4 mm (95% CI, 3.9-4.8 mm) at the inferior clavicle. The mean acromial footprint width of the AC capsule was 4.6 mm (95% CI, 4.2-4.9 mm) at the superior side and 4.0 mm (95% CI, 3.6-4.4 mm) at the inferior side. The mean distance from the lateral clavicular attachment of the AC capsule to the clavicular cartilage border was 4.3 mm (95% CI, 4.0-4.6 mm), and the mean distance from the medial acromial attachment of the AC capsule to the acromial cartilage border was 3.1 mm (95% CI, 2.9-3.4 mm). On the clockface model of the right shoulder, the clavicular attachment of the posterosuperior ligament ranged from the 9:05 (range, 8:00-9:30) to 11:20 (range, 10:00-12:30) position, and the acromial attachment ranged from the 12:20 (range, 11:00-1:30) to 2:10 (range, 13:30-14:40) position.

CONCLUSION

The finding that the posterosuperior ligament did not course perpendicular to the AC joint but rather was oriented obliquely to the long axis of the clavicle, in combination with the newly developed clockface model, may help surgeons to optimally reconstruct this ligament.

CLINICAL RELEVANCE

Our results of a narrow inferior footprint and a short distance from the inferior AC capsule to cartilage suggest that proposed reconstruction of the AC joint capsule should focus primarily on its superior portion.

High degree of consensus achieved regarding diagnosis and treatment of acromioclavicular joint instability among ESA-ESSKA members

PURPOSE

To develop a consensus on diagnosis and treatment of acromioclavicular joint instability.

METHODS

A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when ≥ 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data.

RESULTS

A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similar CONCLUSION: A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified.

LEVEL OF EVIDENCE

Level V.

Functional reconstruction of severe hand injuries using allogeneic tendons: a retrospective study

Objective

To evaluate the effectiveness and safety of allogeneic tendons for functional reconstruction of severe hand injuries.

Methods

From August 2007 to July 2014, we performed functional reconstruction with tendon allografts for severe hand injuries affecting two or more tendons. At the final follow-up, we assessed total active motion (TAM); pincer pinch strength; grip strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; degree of satisfaction; and adhesion. We measured the white blood cell count, C-reactive protein concentration, erythrocyte sedimentation rate, total T-cell count, and CD4⁺T/CD8⁺T ratio to evaluate the immune response and check for infection.

Results

Ten patients received 26 allogeneic tendons to reconstruct hand function. The average follow-up period was 50.0 months (range, 24–82 months). The TAM was 126.4° (12°–253°), pincer pinch strength was 0.83 kg (0–4.5 kg), and grip strength was 13.69 kg (4–41.5 kg). The DASH score was 14.25 (3.3–30.8), and seven and three patients were satisfied and partially satisfied, respectively. One patient developed tendon adhesion. All immune and infectious parameters were within the reference range.

Conclusion

Functional reconstruction using allogeneic tendons for severe hand injuries with multiple tendon defects was effective and safe; however, more research is needed.

Chronic acromioclavicular dislocations: multidirectional stabilization without grafting

Objective

Clinical and radiological evaluation of the surgical treatment of chronic acromioclavicular (AC) dislocations with triple button device and AC joint augmentation.

Materials and Methods

This retrospective study included 21 patients with chronic AC dislocations. All patients underwent bilateral-weighted Zanca and Alexander views as well as the Constant score (CS) and Acromioclavicular Joint Instability Scoring System (ACJI).

Results

A total of 21 patients (19 men and 2 women) with the mean age of 30.7 ± 11.7 years (range, 19-62 years) were able to participate in clinical and radiographic follow-up. After a mean follow-up of 49.7 ± 17.1 months (range, 13-60 months), the results of the CS were 95.2 ± 5.5 (range, 85-100) and ACJI test 89.7 ± 7.9 (range, 75-100), showing no significant differences with the uninjured shoulder (CS, 96.2 ± 3.9; range, 85-100; ACJI, 95.7 ± 4.1; range, 85-100). At the final review, we observed that the preoperative coracoclavicular distance (Zanca view) improved from 12.8 ± 1.5 mm to 8.5 ± 1.3 mm and the AC distance (Alexander view) from 7.8 ± 2.3 mm to 0.99 ± 0.91 mm. Compared with healthy shoulder, these differences were not significant. Osteoarthritis or radiological calcifications were not associated with worse clinical outcomes.

Conclusion

The triple button device is an acceptable alternative surgical method for chronic AC joint dislocations. The surgical technique is simple; it does not need a graft, nor does it present major complications, and material extraction is unnecessary.

[Effectiveness of arthroscopic assisted double Endobutton "8" buckle fixation in treatment of Rockwood type acute acromioclavicular joint dislocation]

OBJECTIVE

To investigate the short-term effectiveness of arthroscopic assisted double Endobutton "8" buckle fixation in the treatment of Rockwood Ⅲ type acute acromioclavicular joint dislocation.

METHODS

The clinical data of 12 patients with Rockwood Ⅲ type acute acromioclavicular joint dislocation who were treated with arthroscopic assisted double Endobutton "8" buckle fixation between June 2016 and June 2019 were analyzed retrospectively. There were 8 males and 4 females, with an average age of 47.0 years (range, 36-58 years). There were 4 cases of left shoulder and 8 cases of right shoulder. The causes of injury included traffic accident injury in 7 cases and falling injury in 5 cases. The average time from injury to operation was 5.0 days (range, 3-14 days). Before operation and at last follow-up, the shoulder joint activity was recorded; the improvements of function and pain were evaluated by Constant score and visual analogue scale (VAS) score, respectively; the reduction was evaluated by measuring the coracoid spacing of the affected side on the anteroposterior X-ray film of shoulder joint.

RESULTS

All 12 cases were followed up 6-36 months, with an average of 20.6 months. All the incisions healed by first intention. There was no complications such as clavicle and coracoid fractures and Endobuton displacement. At last follow-up, the range of motion of the abduction improved from preoperative (77.5±4.5)° to (162.5±6.5)°, the range of motion of forward flexion improved from (84.1±5.2)° to (169.5±5.8)°, the Constant score improved from 42.5±2.3 to 92.4±2.3, the VAS score improved from 5.4±0.8 to 0.6±0.5, and the coracoid spacing reduced from (20.5±1.4) mm to (9.2±0.6) mm, all showing significant differences ( P<0.05).

CONCLUSION

Arthroscopic assisted double Endobutton "8" buckle fixation for the treatment of Rockwood Ⅲ type acute acromioclavicular joint dislocation is safe, less invasive, and quicker recovery. It can effectively alleviate shoulder pain, significantly improve the mobility of the shoulder joint, and achieve good short-term effectiveness.

The frequency of reduction loss after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device, and its effect on clinical and radiological results

Background

The aim of this study was to investigate the effect of reduction loss of more than 3 mm on clinical and radiological results after at least 2 years of follow-up after arthroscopic fixation of acute acromioclavicular joint dislocations using a double-button device.

Methods

Thirty-six patients who had acute (< 3 weeks old), type III or V acromioclavicular (AC) joint dislocations underwent arthroscopic fixation of the AC joint using a double-button device. Clinical and radiological evaluations were performed at preoperative, postoperative first day, 3 months and last follow-up. When the coracoclavicular (CC) distances of patients at the last follow-up were compared to the early postop CC distances, those with a difference of 3 mm or less were grouped as group A and those with a difference of more than 3 mm were grouped as group B.

Results

There was no statistically significant difference between the groups in terms of age, gender, follow-up time, time from injury to surgery, return to work, and distribution of Rockwood classification. Pre-operative CC distance was reduced from 18.7 ± 3.5 to 8.5 ± 0.6 in the early postoperative period. Anatomic reduction was achieved in all patients compared with the unaffected side (CC distance 8.6 ± 0.7). However, the CC distance increased to 9.9 ± 1.5 at the third-month follow-up and increased to 11 ± 2.7 at the last follow-up. There were no significant Constant score differences between the groups in the preoperative and last follow-up periods (p > 0.05). At the last follow-up, the mean Acromioclavicular Joint Instability (ACJI) score of group A was 84.4 ± 8, whereas it was 68.3 ± 8.3 for group B, and the difference was statistically significant (p < 0.01). Furthermore, the subjective evaluation and aesthetic subjective satisfaction values of group B were lower than group A (p < 0.01).

Conclusions

Reduction loss of more than 3 mm was observed in 25% of patients after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device. Although this loss did not create a statistically significant difference in Constant scores, AC joint-specific tests such as ACJI, subjective evaluation, and aesthetic subjective satisfaction values were significantly impaired.

Optimal Management of Acromioclavicular Dislocation: Current Perspectives

Injuries to the acromioclavicular (AC) joint are common and mostly involve younger, male individuals. Whereas the majority of AC joint dislocations can be treated nonoperatively with a trial of immobilization, pain medication, cryotherapy, and physiotherapy, there are patients that do not respond well to conservative management and may require surgical treatment. Identifying and treating these patients according to the type and chronicity of AC joint dislocation is paramount. To date, a myriad of surgical techniques have been proposed to address unstable AC joint dislocations and are indicative of the uncertainty that exists in optimal management of these injuries. Historically research has focused on the restoration of the coracoclavicular ligament complex. However, recently the importance of the acromioclavicular capsule and ligaments has been emphasized. This review aims to provide the reader with an overview of current treatment strategies and research, as well as future perspectives.

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.