Modified Phemister procedure for the surgical treatment of Rockwood types III, IV, V acute acromioclavicular joint dislocation

Assessment of Coracoclavicular Ligament Healing on MRI After Arthroscopic TightRope Fixation for Acute Acromioclavicular Joint Dislocation

Background

Arthroscopic-assisted fixation of acute high-grade acromioclavicular (AC) joint dislocation has gained popularity in the last decade. Coracoclavicular (CC) fixation using the TightRope device is a less invasive technique.

Purpose

To investigate CC ligament healing and functional outcomes after arthroscopic fixation using the TightRope device for acute AC joint disruption.

Study Design

Case series; Level of evidence, 4.

Methods

The study retrospectively analyzed the data of patients admitted for arthroscopic surgical treatment of acute AC joint injury using a single TightRope device. The data collection commenced in October 2021. The Constant-Murley (CM) score and University of California, Los Angeles (UCLA) shoulder score were used for functional evaluation. The CC distance (CCD) was measured on plain radiographs, whereas healing of the CC ligament was evaluated on magnetic resonance imaging (MRI). Statistical analyses were conducted with the Mann-Whitney U test, independent t test, or paired t test, as appropriate.

Results

The analysis included 33 patients with a mean age of 37.7 years (range, 24-49 years) and a minimum follow-up of 24 months. Significant preoperative to postoperative increases were noted in both the CM and UCLA scores (from 34.1 ± 7.6 to 93.3 ± 3.6 and from 8.7 ± 2.1 to 32.9 ± 1.7, respectively; P < .0001 for both). The CCD decreased from 21.8 ± 3.02 mm preoperatively to 10.6 ± 1.2 mm postoperatively (P < .0001). All patients displayed CC ligament healing on MRI. Two patients with superficial infection and 1 case of partial reduction loss were confirmed at the end of this study.

Conclusion

The arthroscopic TightRope technique was found to be a reliable and less invasive method of fixation for acute AC joint disruptions. The CC ligament healed adequately based on MRI evaluation, and the patients regained their preinjury activities, with favorable functional outcomes and minor comorbidities.

Clinical and radiologic outcomes of the modified phemister procedure with coracoclavicular ligament augmentation using mersilene tape versus hook plate fixation for acute acromioclavicular joint dislocation

Background

The clinical superiority of surgical treatment for acromioclavicular (AC) joint dislocation remains controversial. The aim of this study was to compare the clinical and radiological outcomes of the modified Phemister procedure with CC ligament augmentation using Mersilene tape to those of hook plate fixation for acute AC joint dislocation.

Methods

In this study, patients who received modified Phemister surgery with CC ligament augmentation using Mersilene tape (PM group) or hook plate fixation (HK group) for acute unstable AC joint dislocation with a minimum 5-year follow-up period were retrospectively reviewed. The clinical outcomes were evaluated according to blood loss during surgery, surgical duration, visual analogue scale (VAS), Constant-Murley score (CMS), University of California at Los Angeles (UCLA) shoulder rating scale, and the occurrence of complications. Radiological outcomes were assessed from radiographs according to multiple parameters, including CC distance maintenance, acromion osteolysis, and the presence of distal clavicle osteolysis.

Results

A total of 35 patients completed follow-up for more than 5 years and were analyzed in this study (mean = 74.08 months). There were 18 patients in the PM group and 17 in the HK group. The PM group exhibited similar improvement in functional outcome to the HK group. Regarding radiological outcomes, the HK group had a superior performance in terms of CC distance maintenance, of statistical significance (CCDR: 94.29 ± 7.01% versus 111.00 ± 7.69%, p < 0.001) after a one-year follow-up period. However, there were 4 cases of acromion osteolysis and 2 cases of distal clavicle osteolysis in the HK group.

Conclusion

Hook plate fixation was found to be superior to the modified Phemister technique with CC ligament augmentation using Mersilene tape in terms of CC distance maintenance, but there was no significant difference in the functional outcome after 5 years of follow-up. Both surgical methods are reliable options for the treatment of acute AC joint dislocation. Modified Phemister surgery with CC ligament augmentation using Mersilene tape is a relatively lower-cost option for acute AC joint dislocation without the need of a second surgery for implant removal.

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.

Comparison between Trans-articular and Subacromial Stabilization with Ligament Repair for Acute Acromioclavicular Dislocation

Background:

Although numerous treatment options for acromioclavicular joint dislocation have been reported, the treatment strategy is not yet standardized.

Objective:

The purpose of this study was to evaluate the clinical and radiographic results of coracoclavicular ligament repair with temporary acromioclavicular stabilization using suture anchors and Kirschner wires, and to compare the results between temporary trans-articular fixation and subacromial stabilization of the acromioclavicular joint.

Methods:

Thirty-three cases with displaced acromioclavicular joint dislocation were retrospectively evaluated. In the first 14 cases, the wires temporarily penetrated the joint for an average of 7 weeks (trans-articular group), while the acromioclavicular joint was temporarily stabilized by wires passing under the acromion that were inserted into the distal clavicle for an average of 13 weeks in the latter 19 cases (subacromial group). Clinical and radiographic results were evaluated and compared between the two groups.

Results:

The average UCLA score was 32.0 points in the trans-articular group and 32.8 points in the subacromial group, indicating no difference between the two groups (P = 0.418). Coracoclavicular distance ratio after surgery was significantly smaller in the subacromial group (P ≤ 0.035), and acromioclavicular dislocation ratio after removal of the wires was also smaller in the subacromial group (P ≤ 0.001) compared with the trans-articular group.

Conclusion:

This study revealed that coracoclavicular ligament repair with temporary acromioclavicular stabilization leads to favorable clinical results, with the subacromial group showing better maintenance of joint reduction compared with the trans-articular group. Subacromial wire stabilization is a viable option for long-term temporary fixation of acute displaced acromioclavicular joint dislocation.

Clinical and Radiological Outcomes of Modified Phemister Operation with Coracoclavicular Ligament Augmentation Using Suture Anchor for Acute Acromioclavicular Joint Dislocation

Background

Modified Phemister operation has been widely used for the treatment of acute acromioclavicular (AC) joint dislocation. Additionally, the use of suture anchor for coracoclavicular (CC) fixation has been reported to provide CC stability. This study was conducted to evaluate the clinical and radiological results of a modified Phemister operation with CC ligament augmentation using suture anchor for acute AC joint dislocation.

Methods

Seventy-four patients underwent the modified Phemister operation with CC ligament augmentation using suture anchor for acute AC joint dislocation and were followed-up for an average of 12.3 months. The visual analogue scale (VAS), range of motion, Constant score, and Korean shoulder scoring system (KSS) were used for clinical assessment. Acromioclavicular interval (ACI), coracoclavicular distance (CCD), and acromioclavicular distance (ACD) were obtained to evaluate the radiological assessments.

Results

At the last follow-up, the mean VAS Score was 1.7 points, the mean joint range of the forward flexion was 164.6°, external rotation at the side was 61.2°, and internal rotation to the posterior was a level of T12. The mean Constant score and the mean KSS was 82.7 points and 84.2 points, respectively. At the mean ACI, CCD, and ACD, significant differences were found preoperatively and at the last follow-up. When the ACI, CCD, and ACD were compared with the contralateral unaffected shoulder at the last follow-up, the affected shoulders had significantly higher values.

Conclusions

The modified Phemister operation with CC ligament augmentation using suture anchor is clinically and radiologically effective at acute AC joint dislocation.

A novel hybrid fixation (coracoclavicular screw supplemented with K-wire) for the treatment of acute acromioclavicular joint dislocation: A prospective study

OBJECTIVE

The aim of this study was to compare the radiological and clinical outcomes of clavicular hook plate fixation and the coracoclavicular lag screw supplemented with K-wire fixation in the treatment of acute acromioclavicular joint dislocation.

METHODS

Between January 2012 to December 2015, 81 patients with acute acromioclavicular joint dislocation were included in this prospective study. 43 patients were treated with clavicular hook plate fixation (Group A) and 38 patients were treated with coracoclavicular lag screw supplemented with K-wire fixation (Group B). Incision length, operation duration, blood loss volume, intraoperative fluoroscopy times and length of hospitalization were recorded. Radiographic outcomes, functional outcomes and complications were also recorded.

RESULTS

Both two groups could achieve good radiographic and functional outcomes after operation. Group B exhibited significantly shorter operation duration, shorter length of incision, less blood loss volume and shorter length of hospitalization than Group A (P < 0.001). In addition, significant difference could be found between the two groups regarding the VAS scores three month postoperatively and the final follow-up (P < 0.001). However, there was no significant difference in radiographic and functional outcomes between the two groups (P > 0.05).

CONCLUSION

The two groups can both achieve satisfactory radiological and functional outcomes in treating acute AC joint dislocation. However, CC screw fixation supplemented with K-wire exerts some advantages regarding the incision length, operation duration, blood loss volume, length of hospitalization. Furthermore, it can better relieve the pain caused by dislocation. Therefore, the novel hybrid fixation (CC screw fixation supplemented with K-wire) provides an alternative treatment for acute AC joint dislocation.

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.

Functional Outcomes of Type V Acromioclavicular Injuries With Nonsurgical Treatment

INTRODUCTION

This study investigated nonsurgical management of type V acromioclavicular (AC) injuries to determine functional outcomes and to attempt to identify factors associated with positive results.

METHODS

In a retrospective chart review, patients with radiographic and clinical evidence of type V AC injuries per the Rockwood classification were included in the study. Patients treated nonsurgically for ≥6 months were considered eligible for analysis. Functional outcomes were assessed using Disabilities of the Arm, Shoulder, and Hand (DASH) and American Shoulder and Elbow Surgeons (ASES) scores.

RESULTS

Twenty-two patients with a mean age of 42.2 ± 12.8 years were included in the study. The average coracoclavicular distance at the time of presentation was 26.3 mm (+199%). Mean DASH and ASES scores were 27.8 ± 17.7 and 62.8 ± 17.1, respectively, at an average of 34 months from the time of injury. Patients with normal DASH (≤10) and ASES (>92) scores were younger than those with abnormal scores. At final assessment, 77% of the patients were currently working, with nine patients performing manual labor.

CONCLUSION

Following nonsurgical management of type V AC injuries, most patients are able to return to work but have limited functional outcome scores. A small subset of patients with type V AC injuries can achieve normal functional outcomes with nonsurgical management.

LEVEL OF EVIDENCE

Level IV, Case Series.

Transarticular fixation by hook plate versus coracoclavicular stabilization by single multistrand titanium cable for acute Rockwood grade-V acromioclavicular joint dislocation: a case-control study

BACKGROUND

Hook plate (HP) is popularly used for acute and severely displaced acromioclavicular (AC) dislocations. However, subacromial impingement and acromion osteolysis induced by transarticular fixation are notorious. The current case-control study was to compare transarticular fixation by HP to coracoclavicular (CC) stabilization by single multistrand titanium cable (MSTC).

METHODS

Between January 2006 and August 2009, 24 patients with acute AC dislocations were surgically treated by open reduction and transarticular fixation with HP. These patients were matched to a series of 24 patients, who were managed by CC stabilization with MSTC in the same period. All AC dislocations were graded as Rockwood type V. Implant was removed 8-12 months after the primary operation in all patients, and 12 months at least were needed to assess the maintenance of AC joint. Functional results were evaluated before implant removal as well as in the last follow-up based on Constant-Murley criteria.

RESULTS

There were no differences of demographic data including age, dominant gender and side, injury-to-surgery interval, operation time and follow-up period. In terms of functionality, Constant score was 95.8 ± 4.1 in MSTC group, while 76.7 ± 8.0 in HP group before implant removal (P < 0.001). In detail, MSTC was superior to HP in pain, ROM and activities. Constant score was significantly improved to 86.1 ± 5.7 after hardware removal for patients in HP (P < 0.001). Degenerative change of acromioclavicular joint presented in 16 patients (66.7%) in patients treated by HP, while it was found in only 3 patients (12.5%) treated by MSTC (P < 0.001).

CONCLUSIONS

MSTC is superior to HP for the treatment of Rockwood type-V acromioclavicular dislocation both before and after removal of the implant. Hardware removal is of great benefits for functional improvement in patients treated by HP.

[Therapy of acute acromioclavicular joint instability. Meta-analysis of arthroscopic/minimally invasive versus open procedures]

BACKGROUND

A variety of surgical procedure are desrcibed for the treatment of acute acromioclavicular (AC-) joint injuries. Beside open techniques arthroscopic assisted procedures spread widely. Each surgical technique offers advantages and disadvantages, but none is currently accepted as a gold standard. Therefore, the study aims to review the evidence for arthroscopic and open surgical procedures in the treatment of acute AC joint instabilities.

MATERIAL AND METHODS

According to the Cochrane Handbook for Systematic Reviews of Interventions we conducted a defined search of Medline and Embase database for articles publisher over the last ten years.

RESULTS

The search resulted in 961 studies of which 32 were included in this review and 3 studies were suitable for a meta-analysis. The functional outcome (Constant score) showed a tendency towards better results after arthroscopic procedures (weighted mean difference 5.60, 95% confidence interval 0.36-10.64). There were no significant differences with respect to complication rates, secondary dislocation in the vertical plane, revision surgery and AC joint instability.

CONCLUSION

There is insufficient evidence to inform the surgical management of acute AC joint instability. Due to inconsistent study designs there is no evidence for a general superiority of any of the open or arthroscopic procedures. Randomized, controlled studies are necessary to demonstrate whether arthroscopic techniques show a potential benefit in terms of a better functional outcome.

Arthroscopy-assisted reconstruction of coracoclavicular ligament by Endobutton fixation for treatment of acromioclavicular joint dislocation

OBJECTIVE

The aim of this study was to evaluate the clinical outcomes of arthroscopy-assisted reconstruction of the coracoclavicular (CC) ligament using Endobutton for treating acromioclavicular (AC) joint dislocation.

METHODS

From March 2012 to May 2013, a total of 22 patients with fresh AC joint dislocation (Rockwood type III and type V) were treated with arthroscopy-assisted Endobutton reconstruction of the CC ligament. The regular post-operation follow-up was performed. Shoulder joint function was assessed with Constant-Murley scores. Postoperative efficacy of the surgery was evaluated using the Karlsson criterion.

RESULTS

The 22 patients were followed postoperatively for an average of 24 months (16-31 months). Among them, 20 patients achieved good functional recovery with no pain. Two patients had slight pain in the acromion during shoulder joint motion with limited abduction at 3 months, both of whom had recovered at 6 months. Radiography confirmed anatomical reduction of the AC joint in all patients. At 1 year, the Constant-Murley scores were 93.1 ± 2.4 points on the injured side versus 94.2 ± 2.7 points on the uninjured side. The difference did not reach statistical significance (P > 0.05). Postoperative Karlsson evaluation ranked 20 patients (90.9 %) as grade A and 2 as grade B (9.1 %) at the 3-month follow-up. All patients had become grade A at 6 months. None of the patients had brachial plexus or peripheral vascular injuries.

CONCLUSION

Arthroscopy-assisted reconstruction of the coracoclavicular ligament by Endobutton fixation is a safe, easy method for treating AC joint dislocation. It provides reliable fixation, causes little trauma, and has a fast recovery.

Results of Operative and Nonoperative Treatment of Rockwood Types III and V Acromioclavicular Joint Dislocation: A Prospective, Randomized Trial With an 18- to 20-Year Follow-up

Background:

The optimal treatment of acute, complete dislocation of the acromioclavicular joint (ACJ) is still unresolved.

Purpose:

To determine the difference between operative and nonoperative treatment in acute Rockwood types III and V ACJ dislocation.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

In the operative treatment group, the ACJ was reduced and fixed with 2 transarticular Kirschner wires and ACJ ligament suturing. The Kirschner wires were extracted after 6 weeks. Nonoperatively treated patients received a reduction splint for 4 weeks. At the 18- to 20-year follow-up, the Constant, University of California at Los Angeles Shoulder Rating Scale (UCLA), Larsen, and Simple Shoulder Test (SST) scores were obtained, and clinical and radiographic examinations of both shoulders were performed.

Results:

Twenty-five of 35 potential patients were examined at the 18- to 20-year follow-up. There were 11 patients with Rockwood type III and 14 with type V dislocations. Delayed surgical treatment for ACJ was used in 2 patients during follow-up: 1 in the operatively treated group and 1 in the nonoperatively treated group. Clinically, ACJs were statistically significantly less prominent or unstable in the operative group than in the nonoperative group (normal/prominent/unstable: 9/4/3 and 0/6/3, respectively; P = .02) and in the operative type III (P = .03) but not type V dislocation groups. In operatively and nonoperatively treated patients, the mean Constant scores were 83 and 85, UCLA scores 25 and 27, Larsen scores 11 and 11, and SST scores 11 and 12 at follow-up, respectively. There were no statistically significant differences in type III and type V dislocations. In the radiographic analysis, the ACJ was wider in the nonoperative than the operative group (8.3 vs 3.4 mm; P = .004), and in the type V dislocations (nonoperative vs operative: 8.5 vs 2.4 mm; P = .007). There was no statistically significant difference between study groups in the elevation of the lateral end of the clavicle. Both groups showed equal levels of radiologic signs of ACJ osteoarthritis and calcification of the coracoclavicular ligaments.

Conclusion:

Nonoperative treatment was shown to produce more prominent or unstable and radiographically wider ACJs than was operative treatment, but clinical results were equally good in the study groups at 18- to 20-year follow-up. Both treatment methods showed statistically significant radiographic elevations of the lateral clavicle when compared with a noninjured ACJ.

Mini incision acromio-clavicular joint reconstruction using palmaris longus tendon graft

INTRODUCTION

Conservatively managed acromio-clavicular dislocations leave the patients with significant disability. Various techniques have been described to manage such injuries operatively. However, all such techniques involve exposure of the coracoid and use of metallic implants. We present a series of eight patients managed with small incision and minimal soft tissue dissection using palmaris longus tendon graft. We treated eight patients (all males), with acute acromio-clavicular dislocation with a palmaris Longus tendon graft.

MATERIAL AND METHOD

The mean age of the patients at the time of final follow-up was 28.5 years (range 26-29 years), and the mean follow-up was 18 months (range 14-28 months). Functional assessment was done as per the DASH scores, along with a self-evaluation of the results. The vertical acromio-clavicular distance at final follow-up was compared to that at the time of presentation.

RESULTS

The mean DASH score at final follow-up was 3.01; on self-evaluation, all patients rated their result as good. The patients had no or minimal pain at final follow-up. The mean vertical acromio-clavicular distance reduced from a mean pre-operative baseline values of 10.26 ± 2-1.40 ± 0.855 mm at latest follow-up.

DISCUSSION

This is a mechanically sound technique, which required a small incision and minimal soft tissue dissection. It also does not require exposure of the coracoid, thus almost ruling out chances of significant neuro-vascular injury. The patients did not require any second surgery for implant removal. However, a longer follow-up with a larger number of patients is required to evaluate its long-term results and stability of the repair.

CONCLUSION

Acromio-clavicular reconstruction using the palmaris Longus tendon graft is a simple surgery worth trying by a surgeon not proficient in arthroscopic techniques.