Quality and stability of reduction of operated acromioclavicular dislocation using dual acromioclavicular and coracoclavicular stabilization

INTRODUCTION

Dual stabilization is advocated in acute acromioclavicular dislocation (ACD), but has been little assessed.

OBJECTIVE

This preliminary study performed clinical and radiological assessment of dual acromioclavicular (AC) and coracoclavicular (CC) stabilization in acute ACD. The study hypothesis was that dual stabilization allows satisfactory reduction that remains stable over time.

MATERIALS AND METHODS

A button was used under endoscopy for CC stabilization. For AC stabilization, a short approach was used; the joint was cleansed then stabilized by an anchored tape between the acromion and the clavicle to promote ligament healing. Clinical assessment was based on a visual analog pain scale (VAS), joint range of motion and Quick-DASH and Constant scores. Radiological reduction was assessed on the ratio of CC distance between the operated and healthy sides on two views. MRI was used in follow-up to screen for ligament healing: thickening and continuity.

RESULTS

Thirty-five patients with stage 3-5 acute dislocation were included. At a minimum 24 months' follow-up, mean clinical scores were very satisfactory, with recovery of motion and pain relief. Radiography showed 94% stable reduction in both vertical and horizontal planes. MRI confirmed CC and AC ligament healing. Postoperative complications mainly comprised 4 cases of reduction loss (11%). One clavicle fracture occurred, at 6 months.

CONCLUSION

Dual AC-CC stabilization provided very good radiographic reduction in both horizontal and vertical planes. Functional results were very satisfactory, and complications were few, with some cases of reduction loss. These good results encourage us to continue with dual stabilization in acute ACD.

LEVEL OF EVIDENCE

II; prospective cohort.

Return to Play After Surgical Treatment for Acromioclavicular Joint Dislocation: A Systematic Review

BACKGROUND

Acromioclavicular (AC) joint dislocation is a common clinical problem among young and athletic populations. Surgical management is widely used for high-grade dislocations (Rockwood III-VI) and in high-demand athletes at high risk of recurrence.

PURPOSE

To systematically review the evidence in the literature to ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after surgical treatment for AC joint dislocation.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted in the PubMed database. Clinical studies were eligible for inclusion if they reported on RTP after surgical treatment for AC joint dislocation. Statistical analysis was performed with SPSS.

RESULTS

We found 120 studies including 4327 cases meeting our inclusion criteria. The majority of patients were male (80.2%), with a mean age of 37.2 years (range, 15-85) and a mean follow-up of 34.5 months. Most were recreational athletes (79%), and the most common sport was cycling. The overall rate of RTP was 91.5%, with 85.6% returning to the same level of play. Among collision athletes, the rate of RTP was 97.3%, with 97.2% returning to the same level of play. In overhead athletes, the rate of RTP was 97.1%, with 79.2% returning to the same level of play. The mean time to RTP was 5.7 months (range, 1.5-15). Specific RTP criteria were reported in the majority of the studies (83.3%); time to return to play was the most commonly reported item (83.3%). Type III Rockwood injuries had the highest RTP rate at 98.7% and the earliest RTP at 4.9 months. Among the different surgical techniques, Kirschner wire fixation had the highest rate of RTP at 98.5%, while isolated graft reconstruction had the earliest RTP at 3.6 months.

CONCLUSION

The overall rate of RTP was reportedly high after surgical treatment for AC joint dislocation, with the majority of patients returning to their preinjury levels of sport. There is a lack of consensus in the literature for what constitutes a safe RTP, with further focus on this topic required in future studies.

Functional reconstruction of chronic acromioclavicular joint separation using a double suture technique combined with semitendinosus autograft

PURPOSE

We present the functional and clinical results of a combined surgical technique that functionally restores chronic Acromioclavicular Joint Instability (AJI). The method combines a double-looped suture fixation augmented with a semitendinosus autograft.

METHODS

Between 2017 and 2021, 15 patients were treated using the surgical technique. All patients suffered an Acromioclavicular Joint Separation that remained untreated for at least 6 (6-16) weeks after the initial injury. Four Ethibond sutures were passed below the coracoid process and through a 4.5 drill hole in the clavicle. The sutures provided adequate horizontal and vertical reduction and stabilization of the clavicle. A semitendinosus autograft was passed below the coracoid process and looped around the clavicle. The remaining graft limbs were used to reconstruct the acromioclavicular capsule. Patients were radiologically evaluated with bilateral anteroposterior (AP), Zanca, and Alexander views. The clinical evaluation was based on the Acromioclavicular Joint Instability Score and the Constant-Murley Score.

RESULTS

The mean follow-up period was 31.2 months (17-61). The mean last ACJIS and CMS scores were 96 (90-100) and 97.67 (87-100), respectively. Reduction of the clavicle was radiologically confirmed in all cases throughout the follow-up period. AC arthritis was reported in 1 case without associated clinical symptoms. No significant complications were reported, and all patients returned to the pre-injury activity level.

CONCLUSION

The presented functional reconstruction of the AC joint disruption in chronic cases is an effective and secure method with low complication rates and good clinical results.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Self-Designed Endobutton Installation Device for Coracoclavicular Stabilization in Acute Rockwood Type III Acromioclavicular Joint Dislocation

OBJECTIVE

Endobutton technique could provide flexible coracoclavicular (CC) stabilization for acromioclavicular joint (ACJ) dislocation and achieved good clinical outcomes. However, the difficult part of this technique was placement of the Endobutton to the coracoid base. In this study, we designed an Endobutton installation device to place the Endobutton at the coracoid base. And we examined the clinical and radiographic outcomes of patients with acute Rockwood type III ACJ dislocation repaired with Endobutton using this device.

METHODS

We designed an Endobutton installation device to place the Endobutton at the coracoid base to achieve CC stabilization. We retrospectively reviewed 42 patients with acute Rockwood type III ACJ dislocation who underwent CC stabilization with Endobuttons placed either using this novel device (group I, n = 19) or the traditional technique (CC stabilization without using special device, group II, n = 23) from January 2015 to April 2020. The two groups were compared regarding the operative time, intraoperative blood loss, and clinical and radiologic outcomes at final follow-up. The operation-related complications were also evaluated. The Student's t test and the Mann-Whitney U-test were used to compare differences in continuous variables. Differences in categorical variables were assessed with either the Pearson's chi-squared test or Fisher's exact test.

RESULTS

Forty-two patients were clinically followed up for a minimum of 12 months. Compared with group II, group I had a significantly shorter mean operative time (56.05 ± 7.82 min vs. 65.87 ± 7.43 min, p < 0.01) and significantly lesser mean intraoperative blood loss (67.89 ± 14.75 mL vs. 94.78 ± 25.01 mL, p < 0.01). At final follow-up, there were no significant differences between the two groups in the visual analog scale score for pain, Oxford Shoulder Score, Disabilities of the Arm, Shoulder, and Hand score, and postoperative CC distance of the affected side. Loss of reduction occurred in four patients in group I and three patients in group II (p = 0.68); there were no other operation-related complications in either group.

CONCLUSIONS

The Endobutton installation device makes placement of the Endobutton at the coracoid base easier and achieves satisfactory clinical and radiologic outcomes without additional complications in acute Rockwood type III ACJ dislocation.

Clavicular tunnel widening after acromioclavicular joint reconstruction: comparison between single and double clavicular tunnel techniques

Acromioclavicular joint (ACJ) reconstruction using artificial ligaments is a common surgical treatment for Rockwood grade III or higher injuries. These techniques use bone tunnels in the clavicle and coracoid to insert the Tightrope implants. This multicenter retrospective study compares long term radiographic follow up of clavicular tunnel widening in two groups of patients with high-grade ACJ injury who underwent reconstruction using two different surgical techniques. The first group of 23 patients underwent an arthroscopic single clavicular tunnel ACJ reconstruction. The second group of 23 patiënts underwent an open double clavicular tunnel reconstruction. Inclusion criteria are Rockwood grade III or higher injury and minimum 18 months of follow-up. Exclusion criteria are distal clavicle fracture and additional stabilization techniques. Radiographic results were measured on anteroposterior shoulder radiographs taken at the first and last follow-up. Clavicular tunnel widening is the main outcome measurement. Secondary outcomes are heterotopic ligament calcifications, migration of buttons, tunnel fracture and loss of acromioclavicular reduction. The mean clavicular tunnel widening in the single clavicular tunnel technique is 1.91 mm. In the double clavicular tunnel technique, the widening of the medial tunnel is 2.52 mm and 3.59 mm in the lateral tunnel. The difference in widening between the single tunnel and the lateral tunnel is significant (p=0.003). A very clear observation on all follow-up X-rays was a reorientation of the clavicular tunnels towards the coracoid. The double clavicular tunnel technique has more tunnel widening in both tunnels compared to the single bundle technique.

Clavicular tunnel widening after coracoclavicular stabilization surgery: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to (1) estimate the prevalence of clavicular tunnel widening (TW) after coracoclavicular stabilization surgery and its risk factors and (2) assess whether TW is correlated with clavicle fracture or loss of reduction of the acromioclavicular joint (ACJ).

METHODS

In January 2023, 3 electronic databases were searched to collect data on postoperative clavicular TW, its prevalence, magnitude, and correlation with fracture and ACJ loss of reduction. Studies were classified according to the time of surgical intervention, and the clavicular tunnels were categorized by their anatomic location. Mean differences were calculated using a DerSimonian-Laird random-effects model, while binomial outcomes were pooled using the Freeman-Tukey double arcsine transformation. Univariate and multivariate meta-regression analyses were performed to determine the effect of several variables on the proportion of cases with TW.

RESULTS

Fifteen studies (418 shoulders) were included. At the final follow-up, evidence of clavicular TW was found in 70% (95% confidence interval [CI]: 70%-87%; I2 = 89%) of 221 shoulders. Surgeries in acute cases had a lower prevalence of TW (52%) compared to chronic cases (71%) (P < .001). Significant TW was found in the central tunnel (3.2 mm; 95% CI: 1.8-4.6 mm; P < .001; I2 = 72%) for acute injuries and in the medial (1.2 mm; 95% CI: 0.7-1.7 mm; P < .001; I2 = 77%) and lateral (1.5 mm; 95% CI: 0.7-2.3 mm; P < .001; I2 = 77%) tunnels for chronic cases. Single central-tunnel techniques were positively associated with the prevalence of TW (P = .046), while biotenodesis screw fixation was associated with a lower prevalence (P = .004) in chronic cases. Reconstruction of the ACJ ligament complex with tendon grafts or sutures was associated with a higher prevalence of TW (P < .001). Drill sizes between 2.5 and 5 mm were significantly associated with a lower prevalence of TW, regardless of injury chronicity (P = .012). No correlation was found between TW and the loss of ACJ reduction or clavicle fractures.

CONCLUSIONS

This systematic review and meta-analysis explored TW occurrence following coracoclavicular stabilization surgery. TW was observed in 70% of patients at final follow-up, with a higher prevalence in chronic than in acute cases. Modifiable surgical variables, such as single-tunnel tendon graft constructs for acute or chronic injuries and knotted graft procedures for chronic injuries, were significantly associated with TW. Furthermore, the prevalence of TW increased with concomitant surgical treatment of the ACJ ligament complex, and decreased with drill sizes between 2.5 and 5 mm, regardless of lesion chronicity. These surgical variables should be considered when establishing transosseous tunnels for coracoclavicular stabilization. Clavicle fractures and TW mechanisms require further investigation.

Surgical treatment of acromioclavicular joint dislocation of Rockwood III/IV: a retrospective study on clavicular hook plate versus arthroscopic TightRope loop titanium button

PURPOSE

To compare the clinical efficacy of arthroscopic TightRope loop titanium button and clavicular hook plate in the treatment of acromioclavicular joint (ACJ) dislocation of Rockwood III/IV.

METHODS

A retrospective analysis of patients with ACJ dislocation in our hospital from January 2018 to December 2020 was conducted. The patients were assigned to be treated with arthroscopic TightRope loop titanium button (TR group) or clavicular hook plate (HP group). The preoperative, intraoperative and postoperative data and imaging findings of the two groups were compared.

RESULTS

A total of 58 eligible patients were enrolled in this study. Compared with HP group, TR group had shorter incision length and less blood loss during operation. Postoperative follow-up ranged from 12 to 24 months (mean 15.4 months). At 6 months and 12months postoperatively, compared with HP group, TR group had lower VAS and higher CMS, and the difference was statistically significant. At 12 months postoperatively, compared with HP group, TR group had lower ACJ gap and coracoclavicular joint(CCJ) distance, and the difference was statistically significant.In HP group, there were 3 cases of subacromial impact, 1 case of redislocation, 2 cases of traumatic arthritis and 2 cases of wound infection. There was 1 case of redislocation in TR group.

CONCLUSIONS

Compared with clavicular hook plate, arthroscopic TightRope loop titanium button is minimally invasive, safe and effective in the treatment of ACJ dislocation, and has a good trend in clinical application.

[Open reduction and internal fixation in treatment of four cases of bipolar clavicle dislocations]

Objective

To summarize the method and effectiveness of open reduction and internal fixation in the treatment of 4 cases of bipolar clavicle dislocations.

Methods

Between June 2017 and June 2022, 4 patients with bipolar clavicle dislocations were admitted. There were 3 males and 1 female. The age ranged from 27 to 63 years, with an average age of 45 years. There were 2 cases of crushing injury of mine car, 1 case of traffic accident injury, and 1 case of heavy object injury. The time from injury to operation was 3-7 days, with an average of 5.0 days. The sternoclavicular joint dislocations were classified as Grade Ⅱ in 1 case and type Ⅲ in 3 cases, and anterior dislocation in 3 cases and posterior dislocation in 1 case. The acromioclavicular joint dislocations were classified as Tossy type Ⅱ in 2 cases and type Ⅲ in 2 cases. After open reduction, the sternoclavicular joint and acromioclavicular joint were fixed with lateral malleolus locking titanium plate and clavicular hook plate, respectively.

Results

All operations were successfully completed without vascular or nerve injury. All incisions healed by first intention. All patients were followed up 12-18 months, with an average of 14 months. At last follow-up, the shoulder joint functions were rated as excellent in 3 cases and good in 1 case according to Rockwood score. During follow-up, there was no loosening of internal fixator or fracture. The internal fixators were removed in all patients at 5-7 months after operation (mean, 6 months), and no re-dislocation occurred after removal.

Conclusion

For bipolar clavicle dislocation, open reduction combined with lateral malleolus locking titanium plate fixation of the sternoclavicular joint and clavicle hook plate fixation of the acromioclavicular joint can achieve good effectiveness. It has the advantages of simple operation, high safety, firm fixation, and fewer complications, and the shoulder function recovers well.

Suture Button Could Result in More Functional Outcomes Improvement and Pain Relief Than Hook Plate Technique for Treating Acute Acromioclavicular Joint Dislocation: A Systematic Review of Comparative Studies

PURPOSE

To systematically review the current evidence to compare the differences in outcomes of the suture button (SB) versus hook plate (HP) fixations for treating acute acromioclavicular joint dislocation (ACD).

METHODS

Two independent reviewers performed the literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of the Embase, PubMed, and Cochrane Library databases was performed and Level I-IV evidence studies comparing the SB and HP procedures for acute ACD were included. Studies that met the following exclusion criteria were excluded: (1) letters, comments, case reports, reviews, animal studies, cadaveric studies, biomechanical studies, and study protocols; (2) incomplete data; and (3) repeated studies and data. The Newcastle-Ottawa Scale was used to evaluate the quality of nonrandomized studies. Constant score, visual analog scale (VAS) score, operation time, coracoclavicular distance (CCD), and complications were recorded and the mean differences of VAS and Constant were compared with preset minimal clinically important difference.

RESULTS

Fourteen studies with 363 patients treated with SB procedures and 432 patients with the HP procedure were included. In terms of patient-reported outcomes, 5 of the 13 included studies reported significantly greater Constant score in SB group and most (4/5) used arthroscopic SB technique. Statistically significant differences in favor of SB were found in 3 of the 7 included studies in terms of VAS score whereas none of them reached the minimal clinically important difference. In terms of recurrent instability, no statistically significant difference was noted. All studies showed that the SB technique resulted in lower estimated blood loss. No difference was detected in CCD and complications.

CONCLUSIONS

Based on the current body of evidence, it is suggested that employment of the SB technique may confer advantageous outcomes when compared to the HP technique in acute ACD patients. These potential benefits may include higher Constant scores, lower pain levels, and no discernible increases in operation time, CCD, or complication rates.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

In Vivo Analysis of Acromioclavicular Kinematics and Distance During Multiplanar Humeral Elevation

BACKGROUND

Knowledge of acromioclavicular (AC) joint kinematics and distance may provide insight into the biomechanical function and development of new treatment methods. However, accurate data on in vivo AC kinematics and distance between the clavicle and acromion remain unknown.

PURPOSE/HYPOTHESIS

The purpose of this study was to investigate 3-dimensional AC kinematics and distance during arm elevation in abduction, scaption, and forward flexion in a healthy population. It was hypothesized that AC kinematics and distance would vary with the elevation angle and plane of the arm.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 19 shoulders of healthy participants were enrolled. AC kinematics and distance were investigated with a combined dual fluoroscopic imaging system and computed tomography. Rotation and translation of the AC joint were calculated. The AC distance was measured as the minimum distance between the medial border of the acromion and the articular surface of the distal clavicle (ASDC). The minimum distance point (MDP) ratio was defined as the length between the MDP and the posterior edge of the ASDC divided by the anterior-posterior length of the ASDC. AC kinematics and distance between different elevation planes and angles were compared.

RESULTS

Progressive internal rotation, upward rotation, and posterior tilt of the AC joint were observed in all elevation planes. The scapula rotated more upward relative to the clavicle in abduction than in scaption (P = .002) and flexion (P = .005). The arm elevation angle significantly affected translation of the AC joint. The acromion translated more laterally and more posteriorly in scaption than in abduction (P < .001). The AC distance decreased from the initial position to 75° in all planes and was significantly greater in flexion (P < .001). The MDP ratio significantly increased with the elevation angle (P < .001).

CONCLUSION

Progressive rotation and significant translation of the AC joint were observed in different elevation planes. The AC distance decreased with the elevation angle from the initial position to 75°. The minimum distance between the ASDC and the medial border of the acromion moved anteriorly as the shoulder elevation angle increased.

CLINICAL RELEVANCE

These results could serve as benchmark data for future studies aiming to improve the surgical treatment of AC joint abnormalities to restore optimal function.

3D C-arm navigated acromioclavicular joint stabilization

INTRODUCTION

Surgical treatment options for acromioclavicular joint separations are varied. Frequently, suspension devices (SD) are inserted for stabilization under arthroscopic view. This study investigates the feasibility and accuracy of three-dimensional (3D) digital-volume-tomography (DVT) C-arm navigated implantation with regard to the general trend toward increasingly minimally invasive procedures.

MATERIALS AND METHODS

The implantation of a TightRope® suture button system (SD) via a navigated vertical drill channel through the clavicle and coracoid was investigated in 10 synthetic shoulder models with a mobile isocentric C-arm image intensifier setup in the usual parasagittal position. Thereby, in addition the placement of an additive horizontal suture cerclage via a navigated drill channel through the acromion was assessed.

RESULTS

All vertical drill channels in the Coracoclavicular (CC) direction could be placed in a line centrally through the clavicle and the coracoid base. The horizontal drill channels in the Acromioclavicular (AC) direction ran strictly in the acromion, without affecting the AC joint or lateral clavicle. All SD could be well inserted and anchored. After tensioning and knotting of the system, the application of the horizontal AC cerclage was easily possible. The image quality was good and all relevant structures could be assessed well.

CONCLUSION

Intraoperative 3D DVT imaging of the shoulder joint using a mobile isocentric C-arm in the usual parasagittal position to the patient is possible. Likewise, DVT navigated SD implantation at the AC joint in CC and AC direction on a synthetic shoulder model. By combining both methods, the application in vivo could be possible. Further clinical studies on feasibility and comparison with established methods should be performed.

Management of acute grade IV and greater acromioclavicular dislocations: Open acromioclavicular brace versus arthroscopic double DogBone® endobutton

INTRODUCTION

Several surgical techniques exist to manage grade IV acute acromioclavicular dislocation (ACD). However, the conventional acromioclavicular brace technique (ACB) has never been compared to the arthroscopic DogBone® (DB) double endobutton technique. The aim of this work was to compare the functional and radiological results of DB stabilization with those of ACB.

HYPOTHESIS

DB stabilization provides similar functional results with a low rate of radiological recurrences compared to ACB.

MATERIAL AND METHODS

This is a case-control study comparing 17 cases of ACD operated by DB (DB group) between January 2016 and January 2021 with 31 cases of ACD operated by ACB (ACB group) between January 2008 and January 2016. The primary outcome was the difference in the D/A ratio (reflecting vertical displacement) measured on an anteroposterior acromioclavicular (AC) X-ray compared between the 2 groups at one-year after surgery. The secondary outcome was a clinical evaluation at one-year using the Constant score and clinical AC instability.

RESULTS

At revision, the mean D/A ratio in the DB and ACB groups was 0.4±0.5 [-0.4-1.6] and 1.6±0.3 [0.8-3.1] respectively (p>0.05). Two patients (11.7%) in the DB group had implant migration with radiological recurrence while 14 patients (33%) had radiological recurrence in the ACB group (p<0.05).

CONCLUSION

The DB technique limits the radiographic recurrence of acute ACD with an equivalent functional result at 1-year postoperatively compared to the conventional ACB technique, which implicitly requires a second operation for hardware removal. The DB technique has become the technique of choice in first-line treatment of acute grade IV ACD.

LEVEL OF EVIDENCE

III; retrospective case-control series.

Mid-term clinical and sonographic outcomes of minimally invasive acromioclavicular joint reconstruction: mini-open versus arthroscopically assisted

INTRODUCTION

The current literature describes various operative stabilization strategies which achieve good clinical outcomes after acute acromioclavicular joint (ACJ) dislocation. The aim of this study was to compare the mid-term clinical and sonographic treatment outcomes after minimally invasive mini-open and arthroscopic reconstruction.

MATERIALS AND METHODS

We conducted a retrospective two-center study of patients with acute ACJ dislocation. Surgical treatment was performed using either a mini-open approach (MIOP) or an arthroscopic technique (AR). The primary outcome parameters of this study were the sonographically measured acromioclavicular (ACD) and coracoclavicular distances (CCD). Secondary outcome parameters included the Constant-Murley score (CS), range of motion (ROM), postoperative pain scale (VAS), return to daily routine, return to sports, complications, as well as operative revisions.

RESULTS

After a mean follow-up of 29 months, 30 patients were included in this study with an average age of 41.3 ± 14.8 years (MIOP) and 41.2 ± 15.4 years (AR). The sonographic ACD (MIOP 9.11 mm vs. AR 8.93 mm, p = 0.41) and CCD (MIOP 25.08 mm vs. AR 24.36 mm, p = 0.29) distances showed no statistically significant differences. Furthermore, there was no statistically significant difference when compared to the contralateral side (p = 0.42). With both techniques, patients achieved excellent clinical outcome parameters without statistically significant differences in CS (MIOP 95 vs. AR 97, p = 0.11) and VAS (MIOP 1.76 vs. AR 1.14, p = 0.18). The return to daily activity and return to sport rates did not differ. There were neither complications nor revisions in both groups.

CONCLUSION

Both minimally invasive techniques for acute ACJ stabilization achieved excellent clinical and sonographic outcomes without one technique being statistically superior to the other.

Iatrogenic Excessive Clavicle Resection as a Complication of Arthroscopic Distal Clavicle Excision

Arthroscopic distal clavicle excision (DCE) is a reliable procedure to treat acromioclavicular joint arthritis. Typically, only 1 to 2 cm of distal clavicle should be removed. Resection of too much bone can lead to instability of the joint or lack of support to the shoulder. We describe 2 patients who had excessive clavicular bone removed arthroscopically, leading to irreparable clavicular pain and dysfunction. The 2 female patients, ages 56 and 60 years, presented to our clinic with continued pain after DCE. Both had pain intractable with nonoperative treatment and loss of range of motion of the shoulder. Radiographs revealed a distal clavicle defect of 7.5 cm in 1 patient. The second patient had a 2-cm distal clavicular defect with an adjacent 2-cm clavicle bone fragment between the defect and residual clavicle shaft. Both underwent surgery with subtotal claviculectomy for pain control. During surgery, 1 patient had a subclavian vein requiring vascular repair. After 1 year of follow-up, both patients had reduced but residual pain and restricted range of motion. Only 1 patient could rejoin her preinjury occupation. Neither patient could continue with preinjury recreational sports. Excessive removal of the distal clavicle during DCE can result in continued pain and disability of the shoulder. Methods to visualize the anatomy of the distal clavicle and its articulation to the acromion should be considered when performing this operation arthroscopically. Reoperation to remove subtotal clavicle has good clinical outcomes but may lead to serious complications due to the proximity to major neurovascular structures. [Orthopedics. 2024;47(1):e57-e60.].

Anatomic acromioclavicular and Coracoclavicular ligament reconstruction with allograft is effective for the management of non-acute acromioclavicular dislocations

OBJECTIVE

to analyze the short-term outcomes of an anatomical technique that reconstructs both the acromioclavicular and coracoclavicular ligaments with the help of a tendon allograft for the management of non-acute acromioclavicular dislocations.

METHODS

this is a prospective longitudinal study of a case series of subjects with symptomatic non-acute (>3 weeks) acromioclavicular dislocations surgically managed with an anatomical reconstruction of both the acromioclavicular and coracoclavicular ligaments using tibial tendon allografts. Outcomes were assessed with simple standardized radiographs and with the Constant-Murley, American Shoulder and Elbow Surgeons (ASES)-shoulder and Quick-DASH (Disabilities of the Arm, Shoulder and Hand) scales; also, the acromioclavicular joint stability and the scapulothoracic kinematics were assessed.

RESULTS

a total of 19 subjects were assessed. There were no intraoperative or early postoperative complications. After a minimum two year follow-up (mean 3.12 years, [standard deviation 1.10 years]), there were significant improvements in all three of the scales: The Constant-Murley score increased from 65.4 (13.0) preoperatively to 92.6 (11.2) at the end of follow-up (p<0.001); the Quick-DASH score improved from 21.3 (6.73) to 13.0(4.58) (p<0.001); and the ASES-shoulder score increased from 56.6 (14.6) to 91.0 (9.86) (p<0.001). The AC joint was stable in both the vertical and the horizontal plane, without residual scapulothoracic dysfunction in 18/19 subjects at the end of follow-up. Only one patient presented a poor functional outcome, with loss of reduction, instability and persistent symptoms. Another subject suffered loss of reduction, though without functional repercussions. Two subjects had asymptomatic distal clavicle osteolysis and two developed radiographic osteoarthritis and were also asymptomatic. Moderate widening of the tunnels was observed in most patients: tunnel size after surgery was 5.1 (0.3) mm versus 5.8 (1.1) mm at the end of follow-up (p = 0.001) but widening was not correlated to final function.

CONCLUSIONS

the anatomical reconstruction of the acromioclavicular and coracoclavicular ligament complexes with a tendon allograft yields excellent clinical outcomes when used in subjects with symptomatic non-acute acromioclavicular dislocations. Secondary tunnel widening, distal clavicle osteolysis and osteoarthritis might be of concern but do not affect clinical outcomes.

The importance of a structured failure analysis in revision acromioclavicular joint surgery: A multi-rater agreement on the causes of stabilization failure from the ISAKOS shoulder committee

BACKGROUND

Acromioclavicular joint (ACJ) stabilizations are associated with a high overall failure rate with 9.5% of these patients requiring subsequent revision surgery. Consequently, understanding the specific cause of primary ACJ stabilization failure is paramount to improving surgical decision-making in this challenging patient cohort.

PURPOSE

To (1) identify risk factors and mechanisms for failure following primary arthroscopically-assisted ACJ stabilization to highlight the importance of conducting a detailed failure analysis and to (2) establish revision strategies based on real-life cases of primary failed ACJ stabilization.

STUDY DESIGN

Level of evidence IV.

METHODS

A survey was shared internationally among members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) shoulder committee. The survey contained failure analysis of 11 real-life cases of failed primary arthroscopically-assisted ACJ stabilization. For each case, a thorough patient history, standardized radiographs, and CT scans were provided. Participants were asked to give their opinion on bone tunnel placement, cause of failure (biological, technical, traumatic, or combined), the stabilization technique used, as well as give a recommendation for revision.

RESULTS

Seventeen members of the ISAKOS shoulder committee completed the survey. Biological failure was considered the most common cause of failure (47.1%), followed by technical (35.3%) and traumatic (17.6%) failure. The majority deemed two modifiable factors (i.e., patient's profession and sport) as well as non-modifiable factors (i.e., patient's age and time from trauma to initial surgery) to be risk factors for failure. In 10 of 11 cases, the correct fixation device was used in the primary setting (90.9%; 52.8-82.4% agreement); however, in eight of those cases, the technique was not performed correctly (80.0%; 58.8-100% agreement). In 8 of all 11 cases, the majority recommended an arthroscopically assisted technique with graft augmentation for revision (52.9-58.8% agreement).

CONCLUSION

Biological failure and technical failure are the most common reason for failure in primary ACJ stabilization followed by traumatic failure. Besides, biological failure can be triggered by technical errors such as clavicular or coracoidal tunnel misplacement. Consequently, a detailed failure analysis including preoperative CT should be conducted on the causes of primary ACJ failure, and, if possible, an arthroscopically-assisted technique with graft augmentation should be prioritized in revision ACJ surgery.

CLINICAL RELEVANCE

ACJ stabilizations are associated with a high overall failure rate - potentially due to biological and technical properties. When encountering failed arthroscopically-assisted ACJ stabilization, a detailed failure analysis should be conducted on the causes of primary ACJ failure. Furthermore, an arthroscopically-assisted revision stabilization is feasible in most cases.

Reversed total shoulder arthroplasty after acromioclavicular joint resection yields equivalent clinical results compared to a matched control group

INTRODUCTION

Reverse total shoulder arthroplasty (RTSA) is a well-establish procedure with increasing incidence. Depending on the medical history, many patients undergo multiple soft-tissue procedures before RTSA. The role of acromioclavicular pathology as well as the consequences of a distal clavicle resection (DCR) before RTSA has not been evaluated yet.

MATERIAL AND METHODS

A retrospective single-center review was performed on all patients undergoing primary RTSA with or without DCR with a minimum follow-up of 2 years. We compared patient-reported outcome measures (Constant score (CS), subjective shoulder values (SSV), and range of motion (ROM)) with a matched control group. The control group consisted of patients treated with a RTSA without DCR and matching was performed for age, sex, operating side, American Society of Anesthesiologists (ASA), body mass index (BMI), and indication. Surgical time and complication rate were recorded.

RESULTS

Thirty-nine patients with a mean follow-up of 63 months (SD 33) were enrolled in the study group. Mean age was 67 years (SD 7) with 44% male patients for both groups. The mean relative CS improved from 43% (SD 17) to 73% (SD 20) in the study group, and from 43% (18) to 73% (22) in the control group. The SSV improved from 29% (SD 17) to 63% (SD 29) in the study group, and from 28% (SD 16) to 69% (SD 26) in the control group (both n.s.). The postoperative ROM did not significantly differ between the two groups. Five patients in the study group and six in the control group had reoperations.

CONCLUSION

Patients who received a DCR before RTSA showed equivalent clinical outcomes compared to a match-control group with RTSA only. Surgical time was not different, and no complication related to the open DCR was observed in the study group. Therefore, we conclude that a prior DCR does not influence the postoperative outcome after RTSA.

LEVEL OF EVIDENCE

Level III: Retrospective comparative study.

Management of Acute High-Grade Acromioclavicular Joint Dislocations: Comparable Clinical and Radiological Outcomes After Bidirectional Arthroscopic-Assisted Stabilization With the Single Low-Profile Suture Button Technique Versus Double-Suture Button Technique

PURPOSE

To compare the 2-year clinical and radiological outcomes of an arthroscopic-assisted bidirectional stabilization procedure using a single low-profile (LPSB) or double-suture button (DSB) technique with additional percutaneous acromioclavicular (AC) cerclage fixation for patients with acute high-grade AC joint dislocation.

METHODS

This retrospective cohort study compared male patients aged between 18 and 56 years with acute high-grade AC joint dislocation fixed with either a LPSB or DSB technique. Patients were examined at least 24 months after surgery. Subjective Shoulder Value (SSV), Taft (TF), and Acromioclavicular Joint Instability (ACJI) scores were evaluated. Coracoclavicular difference, ossification, AC joint osteoarthritis, and dynamic posterior translation (DPT) were assessed on bilateral anteroposterior stress radiographs and modified Alexander views. The revision rate due to implant conflict and duration of surgery were reported. Group outcome differences were analyzed using standardized hypothesis tests.

RESULTS

28 patients aged 39.2 (LPSB) and 36.4 years (DSB) (P = .319; CI: -2.77-8.34) were eligible per cohort. The follow-up was 30.5 (LPSB) and 37.4 months (DSB) (P = .02; CI: -12.73-1.08). LPSB patients rated a significantly higher SSV (93.2% vs 81.9% [DSB]; P = .004). TF and ACJI scores were similar between the groups. Coracoclavicular difference markedly decreased from 12 mm to 3 mm for both cohorts (P < .001). Ossification was identified in over 85% in both cohorts (P = .160; CI -0.77-0.13) and osteoarthritis in 21.4% (LPSB) and 39.3% (DSB) (P = .150). Persistent DPT was found in around 30% for both cohorts (P = .561; CI -0.26-0.48). The revision rates were 0% (LPSB) and 7% (DSB) (P = .491). LPSB surgery was shorter (59.7 vs 71.5 mins [DSB]) (P = .011).

CONCLUSIONS

The results of the LPSB and DSB techniques with additional percutaneous AC cerclage fixation showed comparable outcomes with excellent clinical and satisfactory radiological results. The assessment of the subjective patient satisfaction was in favor of the LPSB technique and no postoperative revision event was observed following this procedure.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Editorial Commentary: Acute Treatment Including Cerclage Result in Best Surgical Outcomes for High-Grade Acromioclavicular Joint Separations

Despite years of research, optimal treatment of acute high-grade acromioclavicular joint (ACJ) separations remains controversial. ACJ separations occur in a "multiplanar" fashion and identification of horizonal plane instability is paramount to differentiate between high-grade versus low-grade injuries. As surgeons, we treat a self-selected group of patients referred for surgery, and our physiotherapy colleagues may rehabilitate many patients with both "low-grade" and "high-grade" separations who compensate. Of importance, ACJ separations stabilized <3 weeks after injury have the best chance of healing in a close-to anatomic position. The addition of the ACJ cerclage augmentation improves horizontal plane stability while the soft tissues heal and likely improves outcome.

Editorial Commentary: Tunnel Widening and Loss of Reduction May Be Inevitable After Acromioclavicular Stabilization With Cortical Suspensory Devices Whether Inset (Top Hats) or Onlay (Buttons)

Despite widely varying techniques, coracoclavicular (CC) stabilization after traumatic, unstable acromioclavicular (AC) joint dislocations shows notable rates of perioperative complications, radiographic loosening, and, ultimately, loss of anatomic reduction. Loss of reduction can occur in upward of 40% of cases after CC repair or reconstruction. Complications and unplanned reoperations can approach 30% and 1.2% to 5.4%, respectively. While we posit that AC joint congruity confers greater shoulder function, anatomic reduction does not always correlate with patient satisfaction or favorable outcomes, which is estimated in up to 88% of surgically treated cases. AC joint repair or reconstruction often uses cortical suspensory button devices to maintain reduction until sufficient soft tissue healing of the CC and AC ligaments. Over time, the so-called windshield wiper phenomenon of the suture-button construct may lead to tunnel osteolysis and, in severe cases, secondary fracture of the coracoid or clavicle. Current efforts to characterize the extent of tunnel widening and ascertain its implications for radiographic outcomes are critical. Whether using inset, low-profile top hat devices or onlay buttons with adjustable loop fixation, loss of AC joint congruity remains unacceptably high. We should strive to more consistently trade a "bump for a scar," not a bump and a scar!

Comparative Analysis of Therapeutic Outcomes Between Modified Loop Plate and Hook Plate for Treating Acute Acromioclavicular Joint Dislocation

Objective

This study aimed to evaluate the clinical efficacy of an enhanced minimally invasive NICE joint technique combined with dual adjustable loop steel plate internal fixation for treating acute acromioclavicular joint dislocation.

Methods

A retrospective analysis was conducted on 63 surgical patients treated with acute acromioclavicular joint dislocation from May 2017 to March 2022. Among them, 33 cases were treated with the clavicle hook plate, and 30 cases were treated with the minimally invasive loop plate. We compared hospitalization duration, incision length, surgical duration, intraoperative bleeding, visual analogue pain scale scores, shoulder joint Constant scores at 6 months before and after surgery, and the incidence of complications between the two groups.

Results

The comparison between the two groups, including hospitalization duration, incision length, surgical duration, intraoperative bleeding volume, and shoulder joint Constant score at 6 months post-surgery, revealed statistically significant differences where the loop plate group had better results. One case (1/33) experienced postoperative complications in the hook plate group, including screw loosening and plate failure. Additionally, there were 8 cases (8/33) of subacromial osteolysis, 10 cases (10/33) of acromial impact, and 5 cases (5/33) of residual shoulder pain. Conversely, only 1 case (1/30) in the loop plate group had residual shoulder pain.

Conclusions

The surgical technique involving the reconstruction of the coracoclavicular ligament using an enhanced minimally invasive NICE junction combined with double adjustable loop steel plate placement in the clavicular small bone canal is characterized by simplicity, safety, minimal invasiveness, excellent functional recovery, fewer complications, and superior clinical efficacy compared to clavicular hook steel plates.

Treatment of coracoid process fractures combined with acromioclavicular joint dislocation using clavicular hook plate

BACKGROUND

The injury mechanism of acromioclavicular (AC) dislocation combined with coracoid process (CP) fracture is not clear, and there is no consensus on its treatment. This study was performed to evaluate the diagnosis of CP fractures combined with AC dislocation and the effectiveness of operative treatment using a clavicular hook plate.

METHODS

Eighteen patients with CP fractures combined with AC dislocation were treated with a clavicular hook plate from May 2012 to June 2021. The patients comprised 10 male and 8 female patients with an average age of 38 years (range, 16-54 years). The injury was caused by falling in 15 patients, traffic accidents in 2 patients, and falling from a height in 1 patient. The Eyres type of CP fracture was type II in 1 patient, type III in 11 patients, type IV in 3 patients, and type V in 3 patients. The Ogawa type of CP fracture was type I in 17 patients and type II in 1 patient. The Rockwood type of AC dislocation was type V in 1 patient, variation type III in 15 patients, and variation type V in 2 patients. The interval from injury to the operation was 3 days (range, 1-7 days). Postoperative complications and CP fracture healing were recorded. Functional assessment at the last follow-up was performed by an independent reviewer using the Constant score and visual analog scale score.

RESULTS

All 18 patients were followed up for a mean period of 49 months (range, 12-123 months). Nine patients had acromion osteolysis and 3 patients had CP fracture nonunion (Eyres type II, III, and V in 1 patient each); however, no patients developed shoulder pain, incision infection, limitation of shoulder movement, clinical symptoms of subcoracoid impingement, or AC dislocation relapse. At the last follow-up, the mean Constant score was 99 (range, 94-100).

CONCLUSIONS

The possibility of CP fracture should be considered in patients with AC dislocation to avoid a missed diagnosis. Fixation with a clavicular hook plate is a feasible treatment for CP fracture combined with AC dislocation and provides a satisfactory outcome. CP fracture healing may be related to the fracture morphology.

Clavicular Tunnel Widening After Acromioclavicular Stabilization Shows Implant-Dependent Correlation With Postoperative Loss of Reduction

PURPOSE

To radiographically describe, quantify, and compare clavicular tunnel widening (cTW) of 2 different types of stabilization devices and investigate a possible correlation between cTW and loss of reduction.

METHODS

In a retrospective analysis of single-center registry data, we compared patients who were treated for an acute AC dislocation (Rockwood types III to V) with either the AC Dog Bone (DB) or low-profile AC (LP) repair systems. On 6-week and 6-month postoperative radiographs, we measured clavicle height and tunnel diameter. We calculated the button/clavicle filling (B/C) ratio to quantify how much of the clavicular tunnel height is covered by the low-profile inlet. The association between B/C ratio and the extent of cTW was defined, and we also compared cTW between treatment groups. Reduction of the AC joint was graded as either stable, partially dislocated or dislocated depending on the AC ratio. A 2-sample t-test was used for comparing cTW progression between the 2 groups. For continuous variables between more than 2 groups, the Kruskal-Wallis test was used.

RESULTS

Of 65 eligible patients, there were 37 and 28 included in the DB and LP groups, respectively. Overall, cTW was conically shaped with transclavicular widening noted in the DB group and cTW developing strictly inferior to the button in the LP group. For both implants, mean maximal cTW was 7.1 mm and located at the inferior cortex; the B/C ratio was not associated with increased inferior cTW (r = -0.23, P = .248). Only LP patients with complete loss of reduction had significantly increased cTW (P = .049).

CONCLUSIONS

Conical-shaped cTW is a common implant-independent phenomenon after AC stabilization using suture-button devices. It occurs only at the suture-bone interface and is less excessive for the LP implant. There is an association between increased cTW and loss of reduction specific to the LP implant only.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Arthroscopic Repair and Reconstruction of Coracoclavicular Ligament

Acromioclavicular joint separations are common shoulder injuries that require prompt recognition, diagnosis, and treatment. Deciding on a treatment algorithm relies on a detailed knowledge of anatomy and a thorough understanding of the specific functional demands of the patient in question. When a repair or reconstruction is indicated, arthroscopic assistance can be a helpful tool to ensure a safe, anatomic reconstruction that minimizes morbidity and maximizes the potential return to high-level function.

Risk for Fracture with Acromioclavicular Joint Reconstruction and Strategies for Mitigation

Acromioclavicular (AC) joint injuries are a common cause of shoulder pain, especially among athletes. Surgical reconstruction of the AC joint can lead to complications such as fracture of the coracoid process, clavicle or acromion, which can negatively affect the patient's outcome. The purpose of this review is to discuss the risk factors for fractures associated with AC joint reconstruction, as well as the strategies that can be used to mitigate this risk. Risk factors for fractures include low mineral density, coracoid/clavicle drilling, larger holes in the coracoid, and the number of tunnels used for reconstruction.

Open Anatomic Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Injuries

Open reconstruction of the coracoclavicular (CC) and acromioclavicular (AC) ligaments results in excellent reduction of severely displaced AC dislocations, most commonly Grades III and V. Anatomic CC reconstruction through clavicular bone tunnels can prevent vertical instability, whereas the addition of an acromial limb of the graft can increase horizontal stability. Autograft tendon is preferred in the young athletic group of collision sports participants, although allograft has had acceptable results. Accessory fixation may be placed to protect the graft during healing, or for severe instability, especially for athletes involved in contact sports.

Management of Acromioclavicular Joint Injuries: A Historic Account

There has been a rapid evolution in best practice management of acromioclavicular (AC) joint injuries. AP, Zanca, scapular Y, and dynamic axillary radiographic views provide optimal visualization of the joint and may assess for the presence of horizontal AC instability. Severity of AC joint pathology is classified according to the 6-tier Rockwood scoring system. Over 160 surgical techniques have been described for AC joint repair and reconstruction in the last decade; as a result, determining the optimal treatment algorithm has become increasingly challenging secondary to the lack of consistently excellent clinical outcomes.

Surgical Pearls and Pitfalls for Anatomic Acromioclavicular/Coracoclavicular Ligament Reconstruction

Injuries to the acromioclavicular (AC) joint are common shoulder injuries in contact/collision athletes. There are a number of different surgical options that can be used to treat these injuries. The majority of these injuries can be treated nonoperatively with an early return to play for type I and II injuries. Surgical intervention and AC/CC (coracoclavicular) ligament reconstruction have excellent postoperative outcomes if complications can be avoided. This review will focus on the pearls and pitfalls for anatomic AC and CC ligament reconstruction for high-grade AC joint injuries.

Suture button placed beneath plate fixation for complex distal clavicle fractures and acromioclavicular joint injuries: a technical note

Patients with complex distal clavicle and acromioclavicular (AC) joint injuries are at risk of loss of reduction, especially when plates are removed postoperatively. The purpose is to review the authors' preferred technique for treatment of distal clavicle and AC joint injuries utilizing combined suture button and plate fixation, aiming to optimize biomechanical strength of fixation and limit loss of reduction after implant removal. Pre-contoured locking plates or hook plates were utilized atop suture buttons to maintain reduction and optimize biomechanical strength. At final follow-up over one year after plate removal and suture button retention in thirteen patients, reduction was maintained to coracoclavicular interval 1.5 ± 1.4 mm less than contralaterally. DASH scores at final follow-up averaged 5.7 ± 2.5 (range: 3.3 - 11.7). Placing suture button fixation prior to and beneath plate fixation in complex AC joint injuries and distal clavicle fractures allows for maintained fixation and prevents loss of reduction after plate removal.

Clinical outcomes for grades III-V acromioclavicular dislocations favor double-button fixation compared to clavicle hook plate fixation: a systematic review and meta-analysis

INTRODUCTION

The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing double-button suture fixation to hook plate fixation for types III-IV acromioclavicular joint dislocation.

METHODS

Systematic review of Medline, Embase, Scopus, and Google Scholar, including all levels 1-3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were included. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. MINORS and modified Coleman Methodology Score (CMS) were used to assess within study quality. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics.

RESULTS

Fifteen studies were included. Three of the four included LOE II and eleven of the LOE III studies had a high risk of bias. Study quality was considered poor and fair for 67% by MINORS criteria and 93% for CMS criteria. The pooled estimate (SMD 0.662) for all clinical outcomes was statistically significant and in favor of button repair (p = 0.0001). The pooled estimate (SMD 0.662) for all VAS pain scores was statistically significant, again in favor of button repair (p = 0.001).

CONCLUSIONS

The results of this meta-analysis demonstrated significantly better outcomes of button repair for acute ACJ dislocations when compared to clavicle hook plate. Button repair is also associated with a 2.2 times lower risk for complications. However, risk of bias is high, and study quality within and between studies was low. These results, therefore, must be viewed with caution.

LEVEL OF EVIDENCE

Level III; systematic review and meta-analysis.

Bibliometric and visualized analysis of arthroscopic treatment of acromioclavicular joint injury

BACKGROUND

Since arthroscopy was discovered to treat acromioclavicular joint injury, people have had great interest and attention to this beautiful and minimally invasive operation, and related research has been increasing worldwide. At present, there is no bibliometric and visualized analysis in this field. The purpose of this study is to explore the research hotspots and trends of arthroscopic treatment of acromioclavicular joint injury through bibliometric and visualized analysis and look forward to the future development direction of clinical practice.

METHODS

The publications on arthroscopic treatment of acromioclavicular joint injury diseases from its establishment to April 2023 were obtained from the Web of Science (WOS) Core Collection database. CiteSpace, VOSviewer, Scimago graphica and Origin were used for bibliometric and visualized analysis.

RESULTS

This study included a total of 330 publications. The number of publications tends to increase every year. The USA has the most significant number of publications and citations. Imhoff AB is the most relevant scholar with the largest number of publications in this field, and the scholar with the highest citation and average citations is Mazzocca AD. Tech Univ Munich, Rush University and Charite are the three institutions with the greatest contribution. Tech Univ Munich, Rush University and Charite are the three institutions with the greatest contribution. In addition, "Arthroscopy-the Journal of Arthroscopic and Related Surgery" and "American Journal of Sports Medicine" are the institutions with the most significant number of publications and average citations, respectively. The most common keywords are "acromioclavicular joint dislocation," "arthroscopic resection," "arthroscopic reconstruction" and "coracoclavicular ligament."

CONCLUSION

The number of publications shows a steady upward trend as a whole. However, there is still a lack of cooperation among countries, institutions and scholars around the world, so various countries, institutions and scholars need to strengthen academic exchanges and expand the field of cooperation, so as to promote further research and development in related fields. However, minimally invasive methods such as arthroscopy are still the hotspots and frontiers in the treatment of acromioclavicular joint injury in the future.

Mini-open vs. arthroscopic double tight-rope reconstruction after acute AC-joint dislocation: a comparison in functional outcome and sports activity

INTRODUCTION

In athletes, acromioclavicular joint disruptions account for up to 50% of all shoulder injuries. In high-grade injuries, surgery is favored to ensure a correct restoration of the joint, especially in young athletes. The aim of this study was to compare the clinical, radiological and sport related outcomes of the arthroscopic stabilization with the fixation of the AC joint in a mini-open approach.

MATERIALS AND METHODS

19 patients treated arthroscopically (ASK) and 26 patients with an acute AC-joint dislocation Rockwood V who had undergone the mini-open (MO) surgery were included. Constant Murley Score (CMS), Taft Score (TS) and the Simple Shoulder Tests (SST) were evaluated. The sports activity level was determined according to Valderrabano and the athlete's recovery of their athletic activity level after surgery according to Rhee. Furthermore, all available X-ray images were analyzed.

RESULTS

Patients in the ASK group achieved an average score of 11.7 ± 0.6 points in the SST, 10.3 ± 1.8 points in the TS and 91.2 ± 11.8 points in the CMS. On average, patients in the MO group achieved results of 10.5 ± 1.4 points in the SST, 11.7 ± 0.7 points in the TS and 91.6 ± 9.8 points in the CMS. The ASK group showed significant difference regarding the CC distance in side comparison (Δ = 3.6 mm), whereas no significant difference was found in the MO group (Δ = 0.8 mm). In comparison of both groups, the posterior as well as the combined translation were significantly greater in the ASK group than in the MO group (posterior: ASK: 24.8 mm, MO: 19.3 mm, combined: ASK: 29.1 mm, MO: 20.9 mm). Residual horizontal instability was greater in the ASK group (43%) than in the MO group (32%). Similar results were achieved in sports activity and the recovery of athletic activity (Valderrabano: ASK: 2.8, MO: 2.6; Rhee: ASK: 1.6, MO: 1.5).

CONCLUSIONS

Both techniques prove to be effective for the stabilization of high-grade AC-joint disruptions in athletes and showed excellent clinical results. From a radiographic standpoint, the mini-open procedure appears superior to the arthroscopic technique. After mini-open surgery postoperative loss of correction is less common and greater horizontal stability is achieved. The results also suggest the mini-open technique is superior to the arthroscopic procedure when aiming to restore the athlete's original level of sports activity.

LEVEL OF EVIDENCE: 1

Functional and radiological outcome of non-operative treated clavicle fractures and its association with acromioclavicular joint arthrosis

BACKGROUND

Clavicle fractures are traditionally treated non-operatively. This study determines the functional outcome of midshaft clavicle fractures treated non-operatively, the factors influencing it, and the incidence of acromioclavicular joint (ACJ) arthrosis.

METHODS

Patients with midshaft clavicular fractures treated non-operatively between 16 and 50 years old with no prior AC joint problems were assessed. Demographics, hand dominance, type of occupation, and smoking status were documented. Functional scoring using DASH score, CM score, and radiological evaluation was done with special tests to diagnose AC joint arthrosis. Two or more positive special tests were considered significant for this study.

RESULTS

101 patients were recruited, 83 male and 18 female patients. The average age of 34.7 ± 13.93 years. The average follow-up was 32.7 months (range: 24-75; SD ± 9.9 months). 48.5% were blue-collar workers, and 60.4% involved the dominant upper limb. 44.6% were cigarette smokers. There was 20 mm and more shortening in 21.8% of subjects. 40.6% had a significant special test, and 36.6% had radiological changes of AC joint osteoarthritis. Positive two or more special tests were significantly associated with radiological evidence of arthrosis (p = .00). The mean DASH score was 28.28 ± 17.4, and the mean CM score was 27.58 ± 14.34. Most have satisfactory to excellent scores. Hand dominance, smoking, and blue-collar work were significantly associated with poorer CM scores, and hand dominance was significant for Dash scores.

CONCLUSION

There is an equal distribution poor, satisfactory and excellent functional outcomes in patients with midshaft clavicle fractures treated non-operatively. The poor outcomes may be attributed to ACJ arthrosis. Hand dominance, smoking and blue-collar work affected the functional outcome. Shortening of the clavicle had no bearing on the clinical and radiological findings of osteoarthritis and functional scores. The presence of two or more positive special tests is an accurate predictor of AC joint arthritis.

Complications after operative treatment of high-grade acromioclavicular injuries

BACKGROUND

Treatment of Rockwood type III-V acromioclavicular (AC) joint injuries remains controversial. Numerous reconstruction techniques have been proposed. The purpose of this study was to describe the complication profile in a large cohort of patients who underwent surgical management of AC joint separations using a variety of reconstruction strategies.

METHODS

All patients who underwent surgery for AC joint injuries from 2013 to 2019 at a single institution were identified. Chart review was performed to capture patient demographics, radiographic measurements, operative techniques, postoperative complications, and revision surgery. Structural failure was defined as a radiographic loss of reduction of greater than 50% when comparing immediate and final postoperative imaging. Logistic regression analysis was performed to identify risk factors for complications and revision surgery.

RESULTS

Of the 279 patients included in the study, 66 (24%) had type III separations, 20 (7%) type IV, and 193 (69%) type V. Fifty-three percent underwent surgery acutely (<6 weeks of injury), and 40% were chronic (>3 months). A total of 252 of the 279 surgeries (90%) were performed open and 27 (10%) were arthroscopically assisted. Allograft was used in 164 of 279 (59%) cases. Specific operative techniques (with or without allograft) included hook plating (1%), modified Weaver Dunn (16%), cortical button fixation (18%), and suture fixation (65%). At mean 28-week follow-up, 108 complications were identified in 97 patients (35%). Complications were identified at mean 20 ± 21 weeks. Sixty-nine structural failures (25%) were identified. Persistent AC joint pain requiring injection, clavicle fracture, adhesive capsulitis, and hardware complications were the other most common complications. Twenty-one patients (8%) underwent unplanned revision surgery at mean 38 ± 28 weeks after the index procedure, with the most common indication for structural failure, hardware complications, or fracture of the clavicle or coracoid. Patients who had surgery after 6 weeks from injury had a significantly greater risk of having a complication (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.34-7.77, P = .009) and a significantly greater risk of having structural failure (OR 2.65, 95% CI 1.38-5.28, P = .004). Patients who had an arthroscopic technique had a greater risk of structural failure (P = .002). Complications, structural failure, and revision surgery were not significantly correlated with use of allograft or specific operative techniques.

CONCLUSION

Surgical management of AC joint injuries is associated with a relatively high complication profile. Loss of reduction in the postoperative period is common. However, the revision surgery rate is low. These findings are important for patient preoperative counseling.

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.

Dynamic Horizontal Instability of the Acromioclavicular Joint: A Case Report

CASE

A 19-year-old female patient with a history of shoulder trauma 6 years ago presented with dynamic horizontal instability of the acromioclavicular joint (ACJ). She was treated with open ACJ reconstruction using gracilis allograft and showed a satisfactory clinical result at 1-year follow-up.

CONCLUSION

Dynamic pure horizontal instability of the ACJ is a rare entity with only 6 cases reported in the literature. Till now, all reported patients who necessitated surgical treatment failed because of residual instability and/or pain. We present the seventh case of this type with a successful clinical outcome.

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.

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

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

Ligament Reconstruction and Interposition Arthroplasty of the Acromioclavicular Joint

Distal clavicle excision (DCE) for acromioclavicular (AC) joint primary osteoarthritis and post-traumatic arthritis has been shown to have good to excellent outcomes. However, there are studies that report significant rates of residual AC joint pain and distal clavicle instability after open and arthroscopic techniques. We describe a surgical technique for management of AC joint primary osteoarthritis, post-traumatic arthritis, and revision DCE that involves DCE with ligament reconstruction and tendon interposition arthroplasty. It provides distal clavicle stability and can theoretically reduce residual AC joint pain secondary to acromial abutment after DCE.

ANATOMICAL AND BIOMECHANICAL ROLE OF STATIC STABILIZERS OF THE ACROMIOCLAVICULAR JOINT

OBJECTIVE

The aim: To determine the anatomical and biomechanical significance of the static stabilizers of the acromioclavicular joint by conducting numerical modeling using the finite element method and experimental investigation.

PATIENTS AND METHODS

Materials and methods: To ensure the study, modeling of the deformation processes of the clavicle and scapula systems with various combinations of ligament damage was conducted. The COMPAS-3D software package was used to build the simulation model, which allowed obtaining models that are closest to reality. To verify the results of the numerical modeling, corresponding studies of the mechanical characteristics and determination of the stiffness of the investigated systems were carried out using the upgraded TIRAtest-2151 testing stand.

RESULTS

Results: The stiffest system is the system in which all ligaments are intact, and the sequence of decreasing stiffness of the system is presented in the following order: damage to lig. trapezoideum; lig. conoideum; lig. claviculo-acoacromiale inferior; lig. claviculo-acoacromiale superior; the coracoclavicular ligament complex; the acromioclavicular ligament complex.

CONCLUSION

Conclusions: Static stabilizers in general, and their components in particular, are characterized by significant anatomical and functional features. The natural stabilization of the acromioclavicular joint is provided by their synergistic interaction, which is the basis for the development and implementation of surgical interventions, the scope of which includes the restoration of both ligament complexes. The loss of stiffness in the «clavicle-scapula» system is significantly more pronounced when lig. acromioclaviculare superior and inferior are damaged (8.5 N/mm) than when lig. conoideum and lig. trapezoideum are damaged (11.6 N/mm).

Acromioclavicular and coracoclavicular ligamentous insertion distances depend on the scapular tilt and decrease with anterior direction of the inferior scapula angle

PURPOSE

A variety of reconstruction techniques exist for the operative treatment of a ruptured acromioclavicular and coracoclavicular ligamentous complex. However, the complication rate remains high; between 5 and 89%. The intraoperative distance between the clavicle, acromion and coracoid is important for the refixation quality. In this study, the influence of scapular deflection on coracoclavicular and acromioclavicular distances was analysed.

METHODS

The ligamentous insertions of 24 fresh-frozen human scapulae were exposed. The coracoclavicular and acromioclavicular ligaments were referenced and captured in a rigid body system using a three-dimensional (3D) measurement arm. The inferior angle of the scapula was manually pulled into maximum anterior and posterior deflection, simulating a patient positioning with or without dorsal scapular support, respectively. Based on the rigid body system, the distances between the ligamentous insertions were calculated. Statistical evaluation was performed by setting the distances in anterior deflection to 100% and considering the other distances relative to this position.

RESULTS

The scapular deflection had a considerable impact on the distance between the ligamentous insertions. Concerning the conoid ligament, the mean distance was almost doubled when the inferior angle pointed posteriorly compared to anterior deflection (195.3 vs 100.0%; p = 0.028). The insertion of the acromioclavicular capsule also showed a significant association with the direction of deflection (posterior = 116.1% vs. anterior = 100%; p = 0.008).

CONCLUSION

Dorsal support shifting the inferior angle of the scapula anteriorly reduces the distance between the ligamentous insertions. Therefore, a patient position on a shoulder table with posterior support of the scapula is recommended to reliability reduce the acromioclavicular joint.

Does the choice of the optic portal influence the radiographic and early functional results in acute acromioclavicular disjunctions?

Exposure of the coracoid process during arthroscopic stabilization of acute acromioclavicular disjunctions (ACDs) can be achieved either by passing an extra- articular optical portal through the subacromial space or by an intra-articular optical route through the glenohumeral joint with opening of the rotator interval. The objective of our study was to compare the impact on the functional results of these two optical routes. This was a retrospective, multicentre study that included patients operated on for an acute acromioclavicular disjunction arthroscopically. The treatment consisted of surgical stabilization under arthroscopy. The surgical indication was retained for an acromioclavicular disjunction of grade 3, 4 or 5, according to the Rockwood classification. Group 1, which consisted of 10 patients, was operated on with an extra-articular subacromial optical route, and group 2, which consisted of 12 patients, was operated on with an intra-articular optical route with opening of the rotator interval according to the habits of the surgeon. A follow-up of 3 months was performed. The functional results were evaluated for each patient using the Constant score, Quick DASH, and SSV. The delays in returning to professional and sports activities were also noted. A precise postoperative radiological analysis made it possible to analyse the quality of the radiological reduction. No significant difference between the two groups was found between the Constant score (88 vs. 90; p = 0.56), Quick DASH (7 vs. 7; p = 0.58), or SSV (88 vs. 93; p = 0.36). The times to return to work (6.8 weeks vs. 7.0 weeks; p = 0.54) and sports activities (15.6 weeks vs. 19.5 weeks; p = 0.53) were also comparable. The quality of the radiological reduction was satisfactory in the two groups and did not depend on the approach. No clinically or radiologically significant differences between the extra-articular and intra-articular optical portals in the surgical treatment of acute ACDs were found. The optical route can be chosen according to the habits of the surgeon.

The correlation between acromial osteolysis and acromion types in the treatment of acromioclavicular joint dislocation with hook plate

This study aimed to radiologically evaluate the effect of hook plates used in the treatment of acromioclavicular joint (ACJ) dislocations on the development of subacromial osteolysis (SAO) according to acromion types. A total of 43 patients with mean age of 38.5 (19-77) years who were diagnosed with AC dislocation and applied neutral clavicular hook plate between 2013 and 2020 were retrospectively evaluated. Acromion types were determined by measuring acromion slope angle on lateral shoulder radiography and 3-dimensional (D)-CT of the patients. Presence of SAO was classified according to the severity of erosion in the subacromial region (grade I: minimal osteolysis, grade II: subacromial erosion <2 mm, grade III: subacromial erosion >2 mm, grade IV: cut-through of the acromion) on postoperative 3D - CT and correlation with acromion types was analyzed. Incidence of SAO was significantly higher among type 1 acromion compared to type 2 and type 3 acromion (P = .003). While osteolysis was observed in 21 patients, no osteolysis was observed in 22 patients. Osteolysis occurred in all patients with type 1 acromion, 7 patients with type 2 acromion, and 5 patients with type 3 acromion. Since the hook tip in the sagittal plane passes posterior to the center of the acromion and the concavity of the subacromial surface is inadequate in the type 1 acromion, we believe that the increased pressure applied by the hook tip on the subacromial cartilage increases the risk of SAO. We predict that the use of hook plates with an angle of 15-20 degrees, similar to the patient's AC angle, rather than neutral hook plate, will reduce the risk of osteolysis in patients with type 1 acromion.

Clavicular hook plate for acute high-grade acromioclavicular dislocation involving Rockwood type V: clinical and radiological outcomes and complications evaluation

Background

The surgical treatment of high-grade acromioclavicular joint dislocation remains a matter of debate. Clavicular hook plate internal fixation was widely used in the treatment of acromioclavicular dislocation because of its easy-to-master surgical technique. This study aimed to evaluate outcomes using hook plate fixation for acromioclavicular dislocation.

Methods

A consecutive series of 57 patients with acute acromioclavicular joint dislocation involving Rockwood type V were treated between November 2013 and September 2019 using hook plate fixation. The functional outcomes (using the visual analogue score, Constant-Murley score, and University of California Los Angeles score), the quality of surgical reduction (using the coracoclavicular distance), and post-operative complications were assessed with about 46 months of follow-up.

Results

The mean Constant-Murley score increased from 72.6 before surgery to 87.6 at final follow-up. The mean University of California Los Angeles score was 14.1 pre-operatively and 31.6 at final follow-up. Meanwhile, the visual analogue scores were significantly reduced from 3.4 pre-operatively to 1.3 post-operatively. The coracoclavicular distance decreased from 19.4 mm pre-operatively to 10.9 mm at the last follow-up. Post-operative functional and radiological outcomes were significantly improved compared with pre-operative outcomes (P < 0.01). The overall excellent and good result was 35.1% (20/57) and 54.1% (31/57), respectively. At follow-up, the overall complication rate was 15.8% (9/57) including subacromial impingement (three patients), acromial osteolysis (three patients), reduction loss (one patient), acromioclavicular joint osteoarthritis (one patient), and calcification (one patient).

Conclusion

Hook plate fixation was a viable treatment approach, and achieved good clinical outcomes in the treatment of acute acromioclavicular dislocation involving V. But some complications of hook plate fixation should not be ignored.

Coracoclavicular Ligament Reconstruction Using TightRope for Delayed Grade III Acromioclavicular Joint Injury After Ipsilateral Diaphyseal Clavicle Fracture Fixation: Surgical Technique and Review of Current Literature

Athletes commonly sustain high-energy direct impact injuries to the shoulder, with acromioclavicular joint (ACJ) injuries accounting for over half. Ipsilateral ACJ injury and diaphyseal clavicle fracture occur nearly 7% of the time. There is limited literature offering treatment suggestions for this unique injury pattern and limited evidence providing guidance to suggest which injury patterns should be treated operatively or nonoperatively. Here, we present successful treatment of a high-level athlete utilizing a Knotless TightRope XP placed through a superior clavicle plate with successful return to full activity at 6 months postoperation. The TightRope technique offers the ability to augment through a preexisting superior clavicular plate in a low-profile manner and promote easy suture tensioning to obtain and maintain reduction of the injured ACJ.

Acromioclavicular joint stabilization with a double cow-hitch technique compared to a double tight-rope: a biomechanical study

INTRODUCTION

The aim of the present biomechanical study was to evaluate the stability of a novel simple and cost-effective mini-open double cow-hitch suture button technique of acromioclavicular (AC) joint stabilization in comparison to a well-established double tight-rope technique.

MATERIALS AND METHODS

A total of 12 fresh-frozen cadaveric shoulders were randomized into two treatment groups. In either a coracoclavicular stabilization with a standard double tight-rope technique (Group 1; n = 6, age 78 years ± 10) or a double cow-hitch with two No. 5 FiberWire strains looped in a bicortical button placed at the bottom of the coracoid process (Group 2; n = 6, age 80 years ± 13). Both techniques were equally augmented with an AC joint cerclage using a FiberTape. All shoulders were tested in a servo-hydraulic material testing machine for elongation/cyclic displacement (in mm) after cyclic loading (70 N cyclical load, 1500 cycles), stiffness (N/mm) and ultimate load to failure (N). The mechanism of failure was recorded. All tests were performed in a previously published testing setup.

RESULTS

After 1500 cycles, group 2 showed a cyclic displacement of 1.67 mm (SD 0.85), compared to 1.04 mm (SD 0.23) cyclic displacement in group 1 (p = 0.11). The cyclic displacement after AC reconstruction in group 1 was 0.36 mm lower than in the native state with intact ligaments (p = 0.19), whereas the cyclic elongation in group 2 was 0.05 mm higher compared to the native situation (p = 0.87). Stiffness after reconstruction was significantly higher in group 1 compared to the native specimen (p = 0.001), in group 2 it was similar as before the reconstruction (p = 0.64). Ultimate load to failure and stiffness were higher in group 1 with 424 N (SD 237) and 68.6 N/mm (SD 8.2), compared to 377 N (SD 152) and 68 N/mm (SD 13.3) in group 2, without reaching statistical significance (p = 0.69 and 0.89). The most common failure modes were clavicular fractures at the tight rope drill holes (n = 2) and clavicular fractures medially at the fixation site (n = 2) in group 1, and coracoid button break-through (n = 3) and clavicular fractures medially at the fixation site (n = 2) in group 2.

CONCLUSIONS

Stabilization of the AC joint with a novel mini-open double cow-hitch suture button technique resulted in a similar low elongation, high stiffness and ultimate load to failure compared to a double tight-rope technique. This cost-effective technique for AC joint stabilization could demonstrate a sufficient biomechanical stability with especially high stiffness and load-to-failure.

LEVEL OF EVIDENCE

Biomechanical study.

Clinical Impact of Malunion After All-Arthroscopic Coracoclavicular Stabilization for Displaced and Unstable Lateral Clavicle Fractures

OBJECTIVE

To evaluate the clinical outcome of lateral clavicle malunion treated with all-arthroscopic coracoclavicular (CC) stabilization.

DESIGN

Retrospective, case series.

SETTING

Department of hand and upper extremity surgery, university hospital center.

PATIENTS

Forty-five patients with unstable and displaced lateral clavicle fracture treated between January 2015 and August 2019 were included in the study.

INTERVENTION

Closed reduction and arthroscopic CC stabilization using cortical buttons.

MAIN OUTCOME MEASUREMENTS

Shoulder pain and active motion. Patient-reported outcome measures included the Constant score, the Subjective Shoulder Value, the AcromioClavicular Joint Instability score, and the Specific AcromioClavicular Score. Radiographic evaluation assessed bony union and malunion.

RESULTS

Mean duration of follow-up was 25 months (12-60 months). Five patients (11%) had lateral clavicle nonunion and 7 (16%) had lateral clavicle malunion (5 in the coronal plane and 2 in the axial plane). Lateral clavicle malunion did not significantly affect clinical or functional outcomes (P > 0.05). Mean active shoulder motion was forward flexion 163 degrees (SD 28), abduction 162 degrees (SD 26), and external rotation 63 degrees (SD 21). On average, the patients scored 88.3 (SD 17.7) in the Constant score, 90% (SD 12) in the Subjective Shoulder Value, 88.8 (SD 9.4) in the AcromioClavicular Joint Instability score, and 11.4 (SD 8.5) for SACS. The overall complication rate was 38% (including 7 malunions, 5 nonunions, 2 adhesive capsulitis, and 3 button malpositions).

CONCLUSIONS

Closed reduction and internal fixation of lateral clavicle fracture with all-arthroscopic CC stabilization using cortical button potentiates bony union but may generate lateral clavicle malunion, which does not affect the clinical or functional outcome. This result can be attributed to CC ligament healing and acromioclavicular joint congruence. All-arthroscopic CC stabilization is a minimally invasive but demanding surgical alternative for managing unstable and displaced lateral clavicle fracture.

LEVEL OF EVIDENCE

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

Hybrid coracoclavicular and acromioclavicular reconstruction in chronic acromioclavicular joint dislocations yields good functional and radiographic results

PURPOSE

Optimal treatment of chronic unstable acromioclavicular (AC) joint dislocations (stage 3-5 according the Rockwood classification) is still debated. Anatomic coracoclavicular (CC) reconstruction is a reliable option in terms of two-dimensional radiographic reduction, clinical outcomes, and return to sports, but there remain concerns regarding anterior-posterior stability of the AC joint with CC ligament reconstruction alone. The aim of the present study was to describe the mid-term results of a new hybrid technique with CC and AC ligament reconstruction for chronic AC joint dislocations.

METHODS

Twenty-two patients surgically treated for chronic AC joint dislocations (grade 3 to 5) were retrospectively reviewed. All patients were assessed before surgery and at final follow-up with the Constant-Murley score (CMS) and the American Shoulder and Elbow Surgeons (ASES) score. The CC vertical distance (CCD) and the CCD ratio (affected side compared to unaffected side) were measured on Zanca radiographs preoperatively, at 6 months postop and at final follow-up. The same surgical technique consisting in a primary fixation with a suspensory system, coracoclavicular ligaments reconstruction with a double loop of autologous gracilis and acromioclavicular ligaments reconstruction with autologous coracoacromial ligament was performed in all cases.

RESULTS

Twenty-two shoulders in 22 patients (19 males and 3 females) were evaluated with a mean age of 34.4 ± 9 years at the time of surgery. The mean interval between the injury and surgery was 53.4 ± 36.7 days. The mean duration of postoperative follow-up was 49.9 ± 11.8 months. According to the Rockwood classification, there were 5 (22.6%) type-III and 17 (77.2%) type-V dislocations. Mean preoperative ASES and CMS were 54.4 ± 7.6 and 64.6 ± 7.2, respectively. They improved to 91.8 ± 2.3 (p = 0.0001) and 95.2 ± 3.1 (p = 0.0001), respectively at final FU. The mean preoperative CCD was 22.4 ± 3.2 mm while the mean CCD ratio was 2.1 ± 0.1. At final FU, the mean CCD was 11.9 ± 1.4 mm (p = 0.002) and the mean CCD ratio was 1.1 ± 0.1 (p = 0.009). No recurrence of instability was observed. One patient developed a local infection and four patients referred some shoulder discomfort. Heterotopic ossifications were observed in three patients.

CONCLUSIONS

The optimal treatment of chronic high-grade AC joint dislocations requires superior-inferior and anterior-posterior stability to ensure good clinical outcomes and return to overhead activities or sports. The present hybrid technique of AC and CC ligaments reconstruction showed good clinical and radiographic results and is a reliable an alternative to other reported techniques.

LEVEL OF EVIDENCE

Level IV.