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Berthold DP, Muench LN, Dyrna F, Mazzocca AD, Garvin P, Voss A, Scheiderer B, Siebenlist S, Imhoff AB, Beitzel K. Current concepts in acromioclavicular joint (AC) instability - a proposed treatment algorithm for acute and chronic AC-joint surgery. BMC Musculoskelet Disord 2022; 23:1078. [PMID: 36494652 PMCID: PMC9733089 DOI: 10.1186/s12891-022-05935-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 10/30/2022] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Daniel P. Berthold
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany ,grid.411095.80000 0004 0477 2585Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Lukas N. Muench
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Felix Dyrna
- Department of Trauma, Hand and Reconstructive Surgery University Hospital Münster, Munich, Germany
| | - Augustus D. Mazzocca
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 USA
| | - Patrick Garvin
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 USA
| | - Andreas Voss
- grid.7727.50000 0001 2190 5763Department of Trauma Surgery, University Regensburg, Regensburg, Germany
| | - Bastian Scheiderer
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Sebastian Siebenlist
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Andreas B. Imhoff
- grid.6936.a0000000123222966Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Knut Beitzel
- Arthroscopy and Orthopedic Sportsmedicine, ATOS Orthoparc Clinic, Cologne, Germany
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Marín Fermín T, Hovsepian JM, Rodrigues Fernandes VM, Terzidis I, Papakostas E, Koh J. Nonanatomic and Suture-Based Coracoclavicular Joint Stabilization Techniques Provide Adequate Stability at a Lower Cost of Implants in Biomechanical Studies When Compared With Anatomic Techniques: A Systematic Review and Meta-Analysis. Arthrosc Sports Med Rehabil 2021; 3:e573-e591. [PMID: 34027471 PMCID: PMC8129474 DOI: 10.1016/j.asmr.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/29/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose To compare the stability and cost of the used implants in nonanatomic and anatomic acromioclavicular joint repair/reconstruction (ACCR) techniques tested in cadaveric shoulder biomechanical studies during the last decade. Methods A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and prospectively registered in PROSPERO. Two independent reviewers searched PubMed, Embase, and Virtual Health Library databases. Studies evaluating 3-direction stability under 70-N loads and load-to-failure protocols with servohydraulic testing systems were included. A meta-analysis of the mean differences of anterior, posterior, and superior direction; relative stability value in 3 directions; superior direction load-to-failure; stability/cost index; and load-to-failure/cost index was performed using a continuous random-effects model and 95% confidence interval. Results Eighteen articles were included. Both non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and load-to-failure. ACCR techniques were biomechanically better in terms of anterior stability (P = .04) and relative stability value (mean difference 64.08%, P = .015). However, supraphysiological stability and failure loads were achieved with non-ACCR techniques at a lower cost of implants. Techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes had the greatest stability/cost index and load-to-failure/cost index among the included techniques (confidence interval 99%). Conclusions Non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and failure loads in controlled biomechanical testing. However, non-ACCR and techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes provide supraphysiologic stability and failure loads at a lower cost of implants. Clinical Relevance Non-ACCR and suture-based techniques may provide more cost-effective and greater value treatment for acromioclavicular joint injury and could be considered in the surgical management of normal activity individuals and cost-sensitive populations.
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Affiliation(s)
- Theodorakys Marín Fermín
- Department of Traumatology. Hospital Periférico de Coche “Dr. Leopoldo Manrique Terrero,” Caracas, Venezuela
- TheMIS Orthopaedic Center, Thessaloniki, Greece
- Address correspondence to Theodorakys Marín Fermín, M.D., Hospital Periférico de Coche “Dr. Leopoldo Manrique Terrero,” Av. Intercomunal con calle Zea, Coche, PO: 1090, Caracas, Venezuela.
| | - Jean Michel Hovsepian
- Department of Orthopaedic Sports Medicine, Chirurgisches Klinikum München Süd, Munich, Germany
| | | | | | - Emmanouil Papakostas
- TheMIS Orthopaedic Center, Thessaloniki, Greece
- Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar
| | - Jason Koh
- NorthShore University Health System, Evanston; University of Chicago Pritzker School of Medicine, Chicago; and Northwestern University School of Engineering. Evanston, Illinois, U.S.A
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Masionis P, Šatkauskas I, Mikelevičius V, Ryliškis S, Bučinskas V, Griškevičius J, Martin Oliva X, Monzó Planella M, Porvaneckas N, Uvarovas V. Biomechanical evaluation of native acromioclavicular joint ligaments and two reconstruction techniques in the presence of the sternoclavicular joint: A cadaver study. J Orthop Surg (Hong Kong) 2018; 25:2309499017730424. [PMID: 28946836 DOI: 10.1177/2309499017730424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Where is over 100 reconstruction techniques described for acromioclavicular (AC) joint reconstruction. Although, it is not clear whether the presence of the sternoclavicular (SC) joint influences the biomechanical properties of native AC ligaments and reconstruction techniques. The purpose of the present study was to investigate the biomechanical properties of native AC joint ligaments and two reconstruction techniques in cadavers with the SC joint still present. MATERIALS AND METHODS We tested eight fresh-frozen cadaver hemithoraces for superior translation (70 N load) and translation increment after 1000 cycles (loading from 20 to 70 N) in a controlled laboratory study. There were three testing groups created: native ligaments, the single coracoclavicular loop (SCL) technique, and the two coracoclavicular loops (TCL) technique. Superior translation was measured after static loading. Translation increment was calculated as the difference between superior translation after cyclic and static loading. RESULTS Native AC ligaments showed significantly lower translation than the SCL ( p = 0.023) and TCL ( p = 0.046) groups. The SCL had a significantly lower translation increment than native AC ligaments ( p = 0.028). There was no significant difference between reconstruction techniques in terms of translation ( p = 0.865) and translation increment ( p = 0.113). CONCLUSIONS Native AC joint ligaments had better static properties than both reconstruction techniques and worse dynamic biomechanical properties than the SCL technique. The SCL technique appeared to be more secure than the TCL technique. The presence of the SC joint did not have an observable influence on test results.
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Affiliation(s)
- Povilas Masionis
- 1 Medical Faculty, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Vilnius University, Vilnius, Lithuania
| | - Igoris Šatkauskas
- 1 Medical Faculty, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Vilnius University, Vilnius, Lithuania
| | - Vytautas Mikelevičius
- 1 Medical Faculty, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Vilnius University, Vilnius, Lithuania
| | - Sigitas Ryliškis
- 1 Medical Faculty, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Vilnius University, Vilnius, Lithuania
| | - Vytautas Bučinskas
- 2 Department of Mechatronics and Robotics, Vilnius Gediminas Technical University, Vilnius, Lithuania
| | - Julius Griškevičius
- 3 Department of Biomechanics, Vilnius Gediminas Technical University, Vilnius, Lithuania
| | - Xavier Martin Oliva
- 4 Medical Faculty, Department of Embryology and Human Anatomy, University of Barcelona, Barcelona, Spain
| | - Mariano Monzó Planella
- 4 Medical Faculty, Department of Embryology and Human Anatomy, University of Barcelona, Barcelona, Spain
| | - Narūnas Porvaneckas
- 1 Medical Faculty, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Vilnius University, Vilnius, Lithuania
| | - Valentinas Uvarovas
- 1 Medical Faculty, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Vilnius University, Vilnius, Lithuania
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GRIŠKEVIČIUS JULIUS, ŠEŠOK ANDŽELA, MIZERAS DEIVIDAS, MASIONIS POVILAS, RYLIŠKIS SIGITAS. BIOMECHANICAL COMPARISON OF THE CORACOCLAVICULAR SPACE FIXATION USING THREE DIFFERENT SUTURE TECHNIQUES. J MECH MED BIOL 2016. [DOI: 10.1142/s0219519416500421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Coracoclavicular space fixation with suture loops is a well-known surgical technique for the treatment of dislocations. However, out of 100 different surgical treatments no single one has been established as a gold standard. The following research aims to improve the technique and focuses on a development of new fixation technique using composite sutures, which would withstand forces during ligament healing process. Three different fixation techniques (one loop and two separate suture loops and W-system) were tested on a custom built mechanical testing device. Applied load was continuously increased at a loading rate of 30[Formula: see text]N/min until the failure of the sutures. Ultimate tensile strength and suture elongation at failure were measured. The W-system had statistically significant higher load to failure and higher stiffness compared to one loop and two separate loops techniques. Biomechanical properties of a suture fixation technique can be improved by connecting them into one system to create particular arrangement of the sutures. The measurements can be easily repeated and this testing protocol can serve as a good starting point to standardize procedures of evaluation of different joint fixation techniques and to develop new ones.
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Affiliation(s)
- JULIUS GRIŠKEVIČIUS
- Department of Biomechanics, Vilnius Gediminas Technical University, J. Basanavicius str. 28, MR–II 2–109 Vilnius, LT–03224, Lithuania
| | - ANDŽELA ŠEŠOK
- Department of Biomechanics, Vilnius Gediminas Technical University, J. Basanavicius str. 28, MR–II 2–109 Vilnius, LT–03224, Lithuania
| | - DEIVIDAS MIZERAS
- Department of Biomechanics, Vilnius Gediminas Technical University, J. Basanavicius str. 28, MR–II 2–109 Vilnius, LT–03224, Lithuania
| | - POVILAS MASIONIS
- Vilnius University Clinic of Rheumatology, Orthopaedic and Reconstructive Surgery, Centre of Orthopaedic and Traumatology, Republican Vilnius University Hospital, Šiltnamių str. 29, Vilnius LT-04130, Lithuania
| | - SIGITAS RYLIŠKIS
- Vilnius University Clinic of Rheumatology, Orthopaedic and Reconstructive Surgery, Centre of Orthopaedic and Traumatology, Republican Vilnius University Hospital, Šiltnamių str. 29, Vilnius LT-04130, Lithuania
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Li Q, Hsueh PL, Chen YF. Coracoclavicular ligament reconstruction: a systematic review and a biomechanical study of a triple endobutton technique. Medicine (Baltimore) 2014; 93:e193. [PMID: 25526435 PMCID: PMC4603104 DOI: 10.1097/md.0000000000000193] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Operative intervention is recommended for complete acromioclavicular (AC) joint dislocation to restore AC stability, but the best operative technique is still controversial. Twelve fresh-frozen male cadaveric shoulders (average age, 62.8±7.8 years) were equally divided into endobutton versus the modified Weaver-Dunn groups. Each potted scapula and clavicle was fixed in a custom made jig to allow translation and load to failure testing using a Zwick BZ2.5/TS1S material testing machine (Zwick/Roell Co, Germany). A systematic review of 21 studies evaluating reconstructive methods for coracoclavicular or AC joints using a cadaveric model was also performed. From our biomechanical study, after ligament reconstruction, the triple endobutton technique demonstrated superior, anterior, and posterior displacements similar to that of the intact state (P>0.05). In the modified Weaver-Dunn reconstruction group, however, there was significantly greater anterior (P<0.001) and posterior (P=0.003) translation after ligament reconstruction. In addition, there was no significant difference after reconstruction between failure load of the triple endobutton group and that of the intact state (686.88 vs 684.9 N, P>0.05), whereas the failure load after the modified Weaver-Dunn reconstruction was decreased compared with the intact state (171.64 vs 640.86 N, P<0.001). From our systematic review of 21 studies, which involved comparison of the modified Weaver-Dunn technique with other methods, the majority showed that the modified Weaver-Dunn procedure had significantly (P<.05) greater laxity than other methods including the endobutton technique. The triple endobutton reconstruction proved superior to the modified Weaver-Dunn technique in restoration of AC joint stability and strength. Triple endobutton reconstruction of the coracoclavicular ligament is superior to the modified Weaver-Dunn reconstruction in controlling both superior and anteroposterior displacements with a failure load that approximates the intact ligament.
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Affiliation(s)
- Qi Li
- From the Department of Orthopaedics Trauma (QL, PL-H, YF-C), Shanghai Medical Trauma Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
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