Double-button fixation provides superior horizontal stability in acute acromioclavicular joint reconstruction: A comparative radiologic analysis.

Background: Optimal treatment for high-grade acromioclavicular (AC) joint dislocations is still not unanimous. Improving horizontal AC stability has been emphasized in recent years. Biomechanical studies and computer simulations have demonstrated that adequate horizontal stability could be restored with an additional AC fixation. We aim to prospectively investigate if AC augmentation leads to better clinical and radiological results. Methods: A total of 70 patients with a mean (± SD) age of 42 ± 11 years with acute AC joint dislocation Rockwood type IIIb and V were prospectively randomized into two equal groups. All patients underwent arthroscopically assisted stabilization using a double coracoclavicular (CC) suspensory system. Group N (No-augmentation group) had no additional fixation across the AC joint, while group T (tape-augmentation group) had additional fixation with tape. Patients were evaluated at 3, 6, and 12 months postoperatively. Primary clinical outcome measures included the Constant-Murley score and the Specific AC Score (SACS). Secondary outcome measures included the Subjective Shoulder Value (SSV), the Simple Shoulder Test (SST), the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure, and the AC Joint Instability (ACJI) Score. Horizontal stability was radiologically measured with overlapping length (OL) and overlapping area (OA). Vertical alignment was measured with the CC distance. All radiological measurements were compared to the uninjured side and expressed in percentages as relative values. Results: There were no significant differences found between groups regarding the Constant score (p = 0.664), SACS (p = 0.518), or any other outcome measure at the one-year follow-up. Pain level (p = 0.635) and strength (p = 0.217) at the one-year mark also showed no significant differences. Clinical drawer testing for residual horizontal instability was non-significant (p = 0.061), but showed a tendency for a more stable AC joint in group T. The CC distance was smaller in group T at 6 and 12 months (p = 0.047 and p = 0.046, respectively). A two-way mixed factorial ANOVA test showed significantly lower CC differences for group T (p = 0.032); however, the gradual increase in CC distance was similar for both groups over time (p = 0.869). No significant differences were found in OL (p = 0.619) or OA (p = 0.236). Conclusions: The results of our study show that both CC stabilization with the double suspensory system alone and with additional AC fixation are effective surgical treatment options for acute AC joint dislocations, without any important clinical differences. CC distance similarly increased over one year in both groups but was better retained in the AC-augmented group, which showed a tendency toward a more stable fixation.

The treatment of type 3 acromioclavicular joint injuries has still controversial issues. In this retrospective study, we aimed to compare the radiological and functional outcomes of the suture anchor and double-button fixation methods for the treatment of type 3 acromioclavicular joint injuries.This study included 20 patients who underwent suture anchor (9 patients) and double-button fixations (11 patients) for isolated type 3 acromioclavicular dislocation. Injuries were classified according to the Rockwood Classification System. Coracoclavicular(CC) distances and anterior translation have been measured pre-operatively and at the 12th month follow-up. Functional evaluation was performed using the DASH, and Constant–Murley scores of the patients were recorded at the12th-month follow-up.The mean age of the patients was 37 (22–50) years in Group 1(double-button group) and 39 (24–56) years in Group 2(suture anchor group). All of the patients were male. There was no statistically significant difference between the DASH and Constant–Murley scores of the 2 groups (P > .05). The mean DASH score of the patients evaluated at the postoperative 12th month was 6.65 (0–38.3) in Group 1 and 2.48 (0–4.2) in Group 2. The mean Constant-Murley score of the patients evaluated at the postoperative 12th month was 89,6 (50–98) in Group 1 and 93,6 (90–98) in Group 2. Comparison of the pre- and post-operative CC distances and pre- and post-operative anterior translation distances of both groups revealed that there was no statistically significant difference between groups regarding postoperative CC distances and anterior translation distances (P > .05).Suture anchor and double-button techniques are reliable treatment methods that are not superior to one another and can yield excellent functional outcomes

One of the most frequent injuries to the upper extremities, acromioclavicular joint (ACJ) dislocation, causes discomfort in daily life and at work, persistent pain, loss of strength, and difficulty managing force. The purpose of this study was to evaluate surgical outcomes in the management of ACJ dislocations using hook plates. Acute ACJ dislocation patients who underwent open reduction internal fixation with hook plates were included in this prospective cohort study. We looked at preoperative demographics, clinical characteristics, and radiographic findings. Coracoclavicular (CC) distance restoration, pain intensity using VAS score at discharge compared to the preoperation period, and shoulder function outcome using the Constant-Murley score (CMS) at two weeks, three months, and the last follow-up were all included in the postoperative assessments. Forty-two patients (32 males/10 females, 44.3 ± 9.9 years old) were included. The mean follow-up time was 9.5 months. Nineteen and 23 patients had Rockwood grades III and V, respectively. The postoperative mean CC distance on the injured side was 9.2 ± 0.8 mm, significantly compared to the pre-operative mean distance. The mean VAS score decreased significantly, demonstrating good pain relief. Shoulder function improved significantly through CMS at all follow-ups. Six patients had complications, including clavicle fracture, loss of fixation, and subacromial bone erosion. Open reduction and internal fixation with hook plates restore CC distances, relieve pain, and improve shoulder function in patients with ACJ dislocations. We endorse the use of this technique for managing ACJ dislocations in young patients because it facilitates prompt rehabilitation and a swift return to work. Keywords: Acromioclavicular Joint, Dislocation, The Rockwood classification, The Constant-Murley Score, Hook Plate DOI： https://doi.org/10.35741/issn.0258-2724.58.3.72

Background: The severity of acromioclavicular (AC) joint dislocation is evaluated through bilateral anterior-posterior radiographs of the AC joint. AC joint dislocations are graded based on the classification system of Rockwood, which is the foundation for further decision-making regarding therapy regimen. Purpose/Hypothesis: The purpose of this study was to simulate technical irregularities in obtaining panoramic views and the effect they might have on the measured coracoclavicular (CC) distance. It was hypothesized that vertical tilt and horizontal rotation of the radiographic panoramic view of the AC joints affect the measured CC distance and, therefore, the Rockwood classification and reliability of the measurement method. Study Design: Level IV, Diagnosis Study, Case Series. Methods: A retrospective analysis including 14 patients with AC joint dislocations and available computed tomography scans of the upper body was conducted. Three-dimensional models of a simulated bilateral panoramic view were tilted and rotated from −15° to 15° in 5° increments around the vertical and horizontal axes. Three raters with different experience levels independently measured the CC distance and repeated this process with a minimum 6-week interval. The intra- and interclass correlation coefficients for intra- and interrater reliability were calculated. Changes in CC distance and Rockwood classification due to rotation or tilt were reported. Results: The measurements of intra- and interclass correlation coefficients in the neutral (0° position) showed a high intra- and interrater reliability (0.878 and 0.952 for intrarater reliability; 0.851 and 0.952 for interrater reliability). By adding vertical tilt and horizontal rotation to simulated panoramic views, the intra- and interreliability of the 3 raters decreased. Vertical tilt showed a higher impact on the measurement reliability than horizontal rotation. In 10 of 14 cases, the initially determined Rockwood classification changed through adding tilt (9/14) or rotation (5/14). In 5 cases, the injury was graded more severe. In 3 cases, the classification was changed to a milder grade according to Rockwood. In 2 cases, the injury was changed to a higher or a lower type in the Rockwood classification, respectively, depending on the amount of tilt or rotation. Of the 10 cases that were reclassified by tilt and rotation, 5 were Rockwood type 3 injuries. Conclusion: Vertical tilt and horizontal rotation in simulated panoramic views of the AC joints were demonstrated to have a significant influence on CC distances and Rockwood classification as well as intra- and interrater reliability. This effect was more pronounced with a higher degree of tilt/rotation. This may affect clinical decision-making, whether to treat this injury nonoperatively or operatively. Clinical Relevance: The panoramic view is widely used as the gold standard for diagnosing and classifying AC joint dislocations according to Rockwood. Thus, it is a decisive criterion to choose the best treatment. This study investigates the reliability of the radiographic diagnosis of AC joint dislocations when adding tilt and rotation, which may occur in clinical practice while obtaining the panoramic view.

IntroductionNumerous surgical techniques to address a type III and type V acromioclavicular (AC) joint separation have been described in the literature, but a preferred standard approach is still in debate. Current approaches include anatomic reduction, coracoclavicular (CC) ligament reconstruction, and anatomic reconstruction of the joint. In this case series, subjects received a surgical approach that avoids metal anchors and utilizes a suture cerclage tensioning system to achieve adequate reduction.Surgical techniqueAn AC joint repair was achieved with a suture cerclage tensioning system, which allows the surgeon to apply a specific amount of force on the clavicle to achieve adequate reduction. This technique repairs the AC and CC ligaments, restoring the anatomy of the AC joint while avoiding some of the common risks and disadvantages associated with metal anchors.MethodsFrom June 2019 to August 2022, 16 patients underwent repair of the AC joint with a suture cerclage tension system. Inclusion criteria included the diagnosis of type III or type V AC joint separation with another concomitant injury, acute and chronic injury, and patients who attended all their postoperative visits. Exclusion criteria included patients who lost to follow-up or patients who missed any of their postoperative visits. Radiographic images were taken during each subject’s preoperative and postoperative visits, and the CC distance was measured to determine the integrity of the all-suture cerclage repair.ResultsOf the 16 patients included in this case series, radiographic images taken during each subject’s postoperative visit showed a stable construct with little changes in the CC distance. The average change in CC distance when comparing the two-week and one-month postoperative follow-up is 0.2mm. The average change in CC distance when comparing the two-week and two-month postoperative follow-up is 1.45mm. The average change in CC distance when comparing the two-week and four-month postoperative follow-up is 2.6mm.ConclusionOverall, an AC joint repair with the suture cerclage tension system can be a viable, cost-effective technique for restoring vertical and horizontal stability. Although follow-up, larger-scale studies are required to determine the biomechanical integrity of the construct with an all-suture approach, this case series presents 16 subjects whose postoperative radiographic images showed only a small change in CC distance at two to four months after surgery.

Objectives:There have been no large studies that directly compare long term outcomes in patients with Rockwood grade III-V acromioclavicular (AC) joint separations treated with acute vs. chronic repair.Therefore, the purpose of this study was to compare post-operative outcomes between patients who undergo high-grade AC joint surgery acutely (<6 weeks) vs chronically (>6 weeks).Methods:A list of all AC joint surgery patients from 2010-2019 was obtained from the medical records. Chart review was conducted to determine patient demographics, time from injury to surgery, injury grade, and surgical technique, as well as outcomes and complications of AC joint surgery. Post-operative American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores were also collected via RedCap. Patient radiographic outcomes were retrospectively reviewed by reviewing preoperative, immediate postoperative, and follow-up AP views of the operative shoulder and measuring the coracoclavicular (CC) interval distance. Loss of reduction was defined as a follow-up change of greater than 5 mm from the immediate post-operative radiographs measurement. Several multivariate analyses were conducted with post-operative ASES, SANE, and CC distance as the outcomes of interest in order to account for demographic differences between groups.Results:Overall, 225 patients (113 acute, 112 chronic) were included in this study with an average follow-up of 3.5±2.8 years, average age of 40±15 years, and 86% being male. Patients in the acute group underwent surgery 2 ± 1 weeks after initial injury while patients in the chronic group underwent surgery 42 ± 35 weeks after injury. Significant differences in patient age, BMI, injury grade, surgical technique utilized, and pre-operative CC distance were observed between groups (all p<0.05) (Table 1). Rates of revision, loss of reduction, infection, fracture, and total complication rate, as well as post-operative ASES scores did not differ between groups. Patients treated acutely had a lower rate of loss of reduction (1.8mm v. 3.2mm, p=.044), a larger decrease in CC distance at latest follow-up compared to pre- operatively (11.8mm v. 9.0mm, p =.002), and better SANE scores (85.5 v. 75.5, p=.032). All other post- operative outcomes did not differ between groups. After controlling for confounding variables such as age, sex, BMI, injury grade, surgical technique, and time from injury to surgery, multivariate analysis found that female patients had lower ASES scores than male patients, while all other variables did not significantly relate to ASES score, SANE score, or post-operative CC distance (Table 2).Conclusions:Patients who underwent AC joint surgery acutely (<6 weeks) had similar post-operative outcomes to patients who underwent surgery chronically (>6 weeks) after initial injury. Multivariate analysis found that time from injury to surgery did not affect post-operative ASES scores, SANE scores, or post-operative CC distance.

Coracoclavicular (CC) ligament augmentation has been a method to treat acromioclavicular (AC) joint dislocation in recent years. The purpose of this paper is to describe our arthroscopic CC ligament augmentation technique in treating type III and V acute AC joint dislocations and to report the early clinical and radiological results. From 2010 to 2011, twelve patients suffering from acute type III or V AC joint dislocations were arthroscopically treated in our department, by CC ligament augmentation after AC joint reduction. The post-operative outcomes were assessed through physical examination, radiographic examination and the Constant-Murley Shoulder Score. All patients post-operatively experienced anatomical reduction in their AC joint dislocation. No intraoperative complications occurred. At a mean follow-up at 24 months (ranging from 18 to 32 months), the mean Constant-Murley Shoulder Score significantly improved from 24.3 pre-operatively to 91.1 post-operatively. No neurovascular complications or secondary degenerative changes of the AC joint were detected in any of the patients. In one case, a second dislocation occurred 1 month post-operation because the patient had had another traumatic injury. This patient accepted a revision operation, but his AC joint eventually fixated into a subluxated position after his second injury. Based on the resultant successful repair in all cases, the arthroscopic CC ligament augmentation method has thus far proven to be a safe and reliable technique for treatment of acute type III or V AC joint dislocation. The arthroscopic CC ligament augmentation with a flip button/polyethylene belt repair is an efficient method to treat acute type III and V AC joint dislocations which should be popularized. IV.

Improved identification of unstable acromioclavicular joint injuries in a clinical population using the acromial center line to dorsal clavicle radiographic measurement

Objectives:Acromioclavicular (AC) joint injuries are common and constitute approximately 3.2% of all shoulder injuries. Traditionally Rockwood Types I and II are treated conservatively, Type III dislocations are controversial, and Types IV, V, and VI AC dislocations are indicated for surgery. Little is known about nonoperative treatment of Type V AC dislocations especially in active populations. The purpose of this study was to compare the outcomes between Type V AC dislocations treated initially with acute surgical intervention versus those treated conservatively and to identify potential risk factors associated with failure of non-operative treatment.Methods:A retrospective review was conducted using an automated search of electronic patient medical records from January 2007 through December 2012 for patients diagnosed with an AC dislocation in the Tripler Army Medical Center Department of Orthopedics. A Type V injury was defined as greater than 100% increase in the coracoclavicular (CC) distance compared to the contralateral side. Patients were excluded if there were no bilateral radiographs, who did not present acutely or who were tertiary referrals.Results:25 patients were identified as having acute Type V dislocations. Acute surgical AC reconstruction was selected in 8 patients and initial conservative therapy 17. In the conservative group: 8 patients (57%) returned to duty without surgery (average 90.3 days); 4 patients had delayed surgery and returned to full duty (average 238.75 days from initial injury); 2 refused surgery and changed careers; and 3 patients were lost to follow up. In the acute surgical group: 6 patients (75%) returned to full duty in an average of 207 days with 3 of those requiring revision surgery; 1 patient was lost to follow up, and 1 patient failed to return to full duty. There was no significant difference in time to return to duty between the acute surgical group and those who underwent delayed surgical reconstruction (p=0.62). In the conservatively treated group, patients who failed conservative treatment and elected for surgery had a mean increase in CC distance of 144% (range 118%-166%) with a mean 22.5mm displacement of the clavicle above the acromion (19.3- 25.1 mm). In conservative group that did not undergo surgery there was an average 141% increase in CC distance (range 102% - 217%) with a mean 17.3mm displacement (12.5-24.22 mm). There was a significant difference in mm of displacement of the clavicle above the acromion in conservatively treated patients who underwent surgical correction and those who did not (p=.035) while there was no significant difference between the CC distance in this same group (p=0.9).Conclusion:No study has compared initial conservative vs. operative management in type V AC joint dislocations. This study demonstrates that initial nonoperative treatment returns a majority of active patients to full duty faster than acute surgical reconstruction. Patients who undergo early operative management do not return at a higher rate, experience a similar rate of revision surgery, and time to return to duty is not significantly shorter than their initial conservative counterparts. Thus, we recommend that type 5 AC joint injuries, even in an active population, should be managed initially conservatively, as it is effective in the majority of patients, and initial surgery offers no advantage.

BackgroundThe aim of this study was to investigate the effect of reduction loss of more than 3 mm on clinical and radiological results after at least 2 years of follow-up after arthroscopic fixation of acute acromioclavicular joint dislocations using a double-button device.MethodsThirty-six patients who had acute (< 3 weeks old), type III or V acromioclavicular (AC) joint dislocations underwent arthroscopic fixation of the AC joint using a double-button device. Clinical and radiological evaluations were performed at preoperative, postoperative first day, 3 months and last follow-up. When the coracoclavicular (CC) distances of patients at the last follow-up were compared to the early postop CC distances, those with a difference of 3 mm or less were grouped as group A and those with a difference of more than 3 mm were grouped as group B.ResultsThere was no statistically significant difference between the groups in terms of age, gender, follow-up time, time from injury to surgery, return to work, and distribution of Rockwood classification. Pre-operative CC distance was reduced from 18.7 ± 3.5 to 8.5 ± 0.6 in the early postoperative period. Anatomic reduction was achieved in all patients compared with the unaffected side (CC distance 8.6 ± 0.7). However, the CC distance increased to 9.9 ± 1.5 at the third-month follow-up and increased to 11 ± 2.7 at the last follow-up. There were no significant Constant score differences between the groups in the preoperative and last follow-up periods (p > 0.05). At the last follow-up, the mean Acromioclavicular Joint Instability (ACJI) score of group A was 84.4 ± 8, whereas it was 68.3 ± 8.3 for group B, and the difference was statistically significant (p < 0.01). Furthermore, the subjective evaluation and aesthetic subjective satisfaction values of group B were lower than group A (p < 0.01).ConclusionsReduction loss of more than 3 mm was observed in 25% of patients after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device. Although this loss did not create a statistically significant difference in Constant scores, AC joint-specific tests such as ACJI, subjective evaluation, and aesthetic subjective satisfaction values were significantly impaired.

Purpose The optimal surgical technique for unstable acromioclavicular (AC) and coracoclavicular (CC) joint injuries has not yet been established. The biomechanical and radiographic effect of the LockDown device, a synthetic ligament for AC joint reconstruction, was evaluated to assess the optimal surgical technique for unstable AC and CC joint injuries. It was hypothesized that the LockDown device would restore AC joint kinematics and radiographic stability to near native values. Methods Three fresh frozen cadaveric torsos (6 shoulders) modelled CC joint motion in their “native,” “severed,” and “reconstructed” states. The effects of stressed and unstressed native, severed, and reconstructed conditions on AC separation and CC distances in anteroposterior, mediolateral, and inferosuperior directions during shoulder abduction, flexion, and scaption were assessed. The analysis of variance (p, 0.05) was used to compare CC distance and peak AC distance in anteroposterior, mediolateral, and inferosuperior directions during shoulder flexion, abduction, and scaption measurements among native, severed, and reconstructed states with unstressed and stressed Zanca radiographic views. Results From radiographic analyses, the CC distance was significantly greater (p=0.001) across the surgical state in stressed versus unstressed views. Mean difference between stressed and unstressed views was 1.8 mm in native state, 4.1 mm in severed state, and 0.9 mm in reconstructed state. The CC distance was significantly greater in the “severed” state (10.4 mm unstressed; 14.5 mm stressed) compared to the “native” state (p=0.016) (6.5 mm unstressed; 8.3 mm stressed) and compared to the “reconstructed” state (p=0.005) (3.1 mm unstressed; 4.0 mm stressed) and significantly less (p=0.008) in the “reconstructed” state compared to the “native” state. CC distances decreased from native to reconstructed, an average of 3.3 mm for unstressed and 4.3 mm for stressed. On average, peak AC joint separation distance in anteroposterior, mediolateral, and inferosuperior directions during shoulder-abduction, flexion, and scaption was shown to be restored to 11.5 mm of native values after reconstruction with LockDown device. Conclusion Reconstruction of AC joint with LockDown synthetic ligament restores motion of clavicle and acromion to near native values, thereby decreasing scapular dyskinesis and enhancing AC joint stability.

Background/Objectives: Acromioclavicular (AC) joint dislocation is a common injury in young, active individuals, typically resulting from a direct shoulder impact. Treatment is guided by the Rockwood classification, with type III and higher injuries often managed surgically. Suspensory fixation systems are widely used, most commonly via a mini-open approach without direct visualization of the coracoid. This study compared clinical and radiological outcomes of open versus mini-open suspensory fixation in acute AC joint dislocation. Methods: This retrospective cohort study included patients treated surgically for Rockwood type III or higher AC joint dislocation between 2015 and 2021. Functional outcomes were assessed using Constant–Murley, ASES, and DASH scores. Pain, range of motion, and coracoclavicular (CC) distance were evaluated postoperatively and at final follow-up, including percentage difference compared with the contralateral side. Redislocation was defined as a ≥50% increase in CC distance (CCD). Complications, including cut-out, reoperations, and CC calcifications, were recorded. Results: Fifty-seven patients were included (mini-open n = 32, open n = 25; 52 men, 5 women). Mean age was 38.1 ± 13 years, with mean follow-up of 6.7 ± 1.5 years. The mini-open group had greater follow-up (90.1 [83.7–95.1]) than the open group (62.2 [60.3–75.4]). The mini-open group showed a significantly greater CCD at final follow-up (median [IQR] 14.7 [11.4–17.4] mm) compared with the open group (9.2 [7.8–11.1] mm). Redislocation occurred in 47% of mini-open versus 8% of open cases (p < 0.01). Functional scores, pain, and complication rates were similar between groups. Conclusions: Open suspensory fixation is associated with superior radiographic stability and lower redislocation rates compared to the mini-open approach, with comparable functional outcomes.

Comparison of Hook Plate Fixation Versus Arthroscopic Coracoclavicular Fixation Using Multiple Soft Anchor Knots for the Treatment of Acute High-Grade Acromioclavicular Joint Dislocations

The ISAKOS Subclassification of Rockwood Type III AC Joint Dislocations in a Stable Type A and an Unstable Type B Is Not Clinically Relevant. A Prospective Cohort Study of 95 Patients Primarily Treated Non-Surgically

AC joint injury is a common disorder with a reported incidence of three to four cases per 100.000. A multitude of surgical techniques has been described for the treatment of the AC joint injuries with no clear consensus regarding the optimal treatment. We hypothesized that we would obtain favorable clinical outcomes using a novel minimally-invasive polymer cerclage wire system compared to other reported techniques in the literature. All adult patients treated with subacute AC separations in our department between the dates of 2014-2017 were retrospectively reviewed clinically and radiographically. Clinical outcomes scores that were obtained preoperatively and postoperatively included ASES score, constant score and the UCLA shoulder rating scale. Five patients with Type 5 AC separations were included in this study who underwent surgical treatment by the same orthopedic surgeon (G.H.) using the same minimally-invasive technique. The mean follow-up period was 22.4 months (range 18 to 29). Mean preoperative coracoclavicular (CC) distance was 19.7 mm (range 16.4 to 24.5 mm) on the surgical side and 9.48 mm on the contralateral side. Mean early postoperative CC distance was 7.1 mm (range 4.5 to 11.2 mm). At the latest follow-up, the mean CC distance was 13.8 mm (range 7.3 to 21.2 mm). Mean preoperative Constant score was 48, the UCLA shoulder rating score was 14.8, and the ASES shoulder score was 49.26. Mean follow up Constant score was 91.6, UCLA shoulder rating score was 33.8 and ASES shoulder score was 93.75. No neurovascular complication was observed after procedure. There were no cases of clinical or radiographic failure or loss of fixation. No AC joint arthritis was observed at the latest follow-up. We present a novel minimally-invasive polymer cerclage wire technique which provides comparable results as other reported arthroscopic and open techniques for Type 5 AC joint separations.