Acromioclavicular Joint Instability Research Articles

Reconstruction of Coracoclavicular Ligaments with Semitendinosus Autograft and Temporary Kirschner Wires is a good option for Chronic Acromioclavicular Joint Instability.

This study reports the results of surgical anatomic reconstruction of torn coracoclavicular ligaments with an autogenous semitendinosus graft and temporary Kirschner wires (K-wires) in chronic acromioclavicular (AC) joint dislocations. Nineteen shoulders underwent surgical anatomic reconstruction of torn coracoclavicular (CC) ligaments with an autogenous semitendinosus tendon graft and temporary K-wires for Rockwood grade III, IV and V chronic AC joint dislocations. Pre-operative data included patients' demographic characteristics, injury characteristics and surgical histories. The primary outcome measures were the University of California Los Angeles (UCLA) shoulder rating scale and visual analogue pain scoring (VAS), and the complications were noted for each patient. Surgical anatomic reconstruction of torn CC ligaments was performed in 19 patients with a mean age of 41.6±16 years (range 21-72 years). All of the patients were satisfied and felt better after CC ligament reconstruction. The average UCLA shoulder rating scale score was good/excellent: 29.4 (range 23-34) out of 35 points. The average pre-operative VAS score was 7.7 points out of 10 and improved to 1.1 points post-operatively (p<0.05). None of the patients experienced failure during the follow-up. One patient had a mild subluxation, but the patient was satisfied with the result. This technique is simple, reliable, and biologic without major complications. It is also a cost-effective procedure since it can be performed with Kirschner wires and autogenous grafts. It has a major advantage of leaving no implants inside the joint, which can lead to hardware complications, and it can be performed in basic operating room settings.

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

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. 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. The mean follow-up period was 31.2months (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. 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. 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 .

Coracoclavicular and acromioclavicular ligament reconstruction with a double-bundle semitendinosus autograft and cortical buttons for chronic acromioclavicular joint dislocations: clinical and imaging outcomes

BackgroundThere are few clinical and radiographic studies of coracoclavicular (CC) ligament reconstruction in chronic acromioclavicular (AC) joint dislocation. Additionally, reported AC joint reduction rates vary. HypothesisArthroscopically assisted double-bundle semitendinosus tendon autografts with CC and AC ligament reconstruction for AC joint reconstruction provide AC joint stability and improved function at the final visit. MethodsIn this retrospective study of prospectively collected data, 21 patients surgically treated for chronic AC joint dislocation (Rockwood III–V) were assessed clinically and radiographically preoperatively, and at day 1, 3 months, 12 months, and at a final visit (> 24 months) postoperatively. Clinical assessments included Constant and ASES scores. The CC vertical distance (CCD) on the affected and unaffected sides [CCD ratio (%)] on the anterosuperior view were measured. AC joint vertical reduction loss was defined as an increase in the CCD ratio of > 25%. Horizontal AC joint instability was evaluated on axillary views. Pearsons’ correlation coefficients were generated to examine the relationships among postoperative clinical scores, CCD ratio, interval from injury to surgery, and age at the time of surgery. ResultsTwenty-one shoulders in 21 patients (mean age, 40.0 years at the time of surgery; 16 men, 5 women) were evaluated with a mean 31.7-month follow-up period. The mean Constant scores, ASES scores, and CCD ratios significantly improved from preoperatively to the final visit [57.4 ± 10.1, 49.1 ± 12.1, 101.6 ± 64.1 preoperatively; 89.6 ± 5.3, 96.5 ± 4.2, 9.9 ± 34.5 at the final visit, respectively (P < 0.001 for all)]. Vertical AC and horizontal AC joint instability were observed in four shoulders (19.0%) and in one shoulder (4.8%), respectively. However, there was no significant correlation between the increase in CCD and clinical scores at the final visit (Constant score; r = 0.179, P = .438: ASES score; r = -0.260, P = .256) or the interval from injury to surgery (r = 0.099, P = .669) or age at the time of surgery (r = 0.019, P = .935). No clinical complications were associated with clinical symptoms. ConclusionsPatients who underwent the index procedure achieved significant improvement in shoulder function without complications related clinical symptom after a mean follow-up interval of 31.7 months. In contrast, the rates of total ACJ instability in the vertical and horizontal planes were unsatisfactory but compatible with those in previous studies.

Presurgical perspective and postsurgical evaluation of acromioclavicular joint instability.

Acromioclavicular joint (ACJ) dislocations are a common cause of pain in patients of any age. Athletes who participate in contact sports, such as hockey, football, rugby, and soccer, are particularly susceptible to such injuries. The ACJ has an important role in the function of the upper limb, and its complexity of movement makes it susceptible to acute injuries and chronic dysfunction with debilitating effects that must be treated appropriately and promptly to preserve function. Recently, ACJ has received increasing attention due to the development of new surgical techniques for the restoration of normal function and stability. There is some agreement about the treatment of ACJ dislocations, but controversy remains about the treatment of Rockwood grade III dislocations, and a new approach to these injuries is suggested by ISAKOS. Overall, the paper summarizes new concepts in the anatomy of the ACJ and reviews the utility of imaging methods in ACJ dislocations as well as their treatment and complications.

THE EFFICACY OF THE BIPOD METHOD, USING AN ARTIFICIAL LARS® LIGAMENT, IN REDUCING ACROMIOCLAVICULAR JOINT INJURIES: A RETROSPECTIVE CASE SERIES

Acromioclavicular joint injuries are one of the most common injuries in the shoulder girdle complex. Surgical management is considered based on patient profile, level of activity, pain, and classification of injury. To date, a vast array of surgical techniques have been proposed and described in the literature, a possible reason being that the optimal solution is still uncertain. The aim of this study is to determine the efficacy of an alternative surgical technique.This study is a retrospective case series of 80 patients that have been operated by a single surgeon over a period of 6 years. A novel surgical technique, the ‘BiPOD method’, was applied where a synthetic artificial ligament (LARS®) is used to reconstruct and reduce the acromioclavicular joint.The technique is done in a reproducible manner, where a single continuous artificial ligament is used to reduce and reconstruct both, the coracoclavicular and acromioclavicular ligament complexes to achieve bidirectional stability. Patients were followed-up postoperatively, either clinically where possible or telephonically. The Acromioclavicular Joint Instability Score (ACJI) and radiographic measurements were used to determine the clinical and surgical outcome of the surgery.Radiographic parameters, measuring the reduction of the coracoclavicular- and acromioclavicular joint, were analysed and documented. The results showed marked improvement in both, the coracoclavicular distance and acromioclavicular distance. Clinically, using the ACJI scoring system, the patients reported substantial improvement in pain and function. Complications were recorded but were insignificant.The BiPOD surgical technique, making use of an artificial LARS® ligament, has proven acceptable outcomes in the surgical management of acromioclavicular joint dislocations.

Paper 55: Kinematic Abnormalities in the Shoulder Girdle after Conservative or Surgical Treatment of the High-grade Acromioclavicular Joint Disruption

Objectives: Acromioclavicular joint (ACJ) injury is one of the most prevalent shoulder girdle injuries among young contact athletes, disrupting shoulder mechanics, which can adversely affect long-term joint health. However, there is considerable controversy regarding treatment selection and its role in the health of the shoulder complex over time. While there is some consensus that surgical treatment is needed when both AC and CC (coracoclavicular) ligaments are disrupted (Rockwood grades III-V), in practice distinguishing between high-grade injuries is challenging, and grading is not highly consistent among surgeons. Clinical studies comparing surgical and conservative treatment have reported comparable patient outcomes. However, they often have included outdated surgical approaches with known high complication rates (e.g., k-wire, hook-plate), undermining their current validity. Overall, data on the efficacy of conservative vs. surgical treatment for restoring ACJ stability and the impact of ACJ instability on shoulder girdle biomechanics is lacking, impairing optimal decision-making for ACJ injury treatment. This cross-sectional biomotion study aims to characterize the extent of biomechanical abnormalities of the shoulder girdle after surgical or conservative treatments in individuals treated for high-grade ACJ injury. Hypothesis: The kinematics of the shoulder girdle will remain abnormal regardless of the treatment type, but the abnormality will be more pronounced in the conservatively treated group. Methods: Subjects: Individuals with a unilateral ACJ injury (Rockwood Grade ³ III; 2-5 years post- treatment) consented and participated in this IRB-approved cross-sectional study. Thus far, in this ongoing study, six subjects (one female, Height: 175 (12) cm, Weight: 81 (18) kg), BMI 26.1(3.1) kg/m2) who were treated surgically using suspensory fixation, and three subjects (179 (10.4) cm, 99.4 (13.6) kg, 30.9 (2.4) kg/m2) who were treated non-operatively were consented and tested. Measurements: A high-resolution 3D shoulder CT scan was acquired bilaterally for each subject. The patient-specific 3D bone models of the humerus and clavicle were created. The 3D in-vivo shoulder kinematics was measured bilaterally (with the contralateral shoulder serving as an internal control) using a Dynamic Stereo X-ray (DSX) system during three repetitions of the scapular plane arm elevation while subjects followed a metronome beat for consistent moving rhythm. Post-processing: The 3D poses of the scapula and clavicle were estimated according to validated methods in DSX-Suite (C-Motion, USA) by simultaneous aligning the bone-model contours acquired through CT to DSX images in both views in each frame. In addition, an anatomical coordinate system was determined for each bone, and joint rotations/translations were calculated according to the methods described elsewhere, which considers the abilities of DSX and CT-based bone models while adhering to ISB standards when relevant. Outcomes: The horizontal and vertical ACJ displacements were calculated in Visual 3D (C- Motion, USA). Also, ACJ separation was defined as an instantaneous Euclidean distance between acromion and clavicle centers, characterizing the ACJ subluxation during movements. The rotational stability of the ACJ was measured by calculating the instantaneous axial rotation of the scapula relative to the clavicle using the helical axis method. These outcomes can substantiate how the mechanical constraint of the shoulder girdle is maintained in surgically and conservatively ACJ-treated individuals during in-vivo muscle-driven activities. Results: Figure (A)-(E) demonstrates the ACJ kinematic results normalized to the movement percent (mean±SE). No difference was noted in the axial rotation of the scapula relative to the clavicle between the study groups (Fig . B). The nonoperative group demonstrated a larger magnitude and range of ACJseparation (Fig. C), while the surgical cohort demonstrated smaller but comparable ranges and variations to controls. Fig. D shows that both treatment groups show increased posterior claviculartranslations, with the conservative group showing poorer ACJ instability in the posterior direction. Also, an increase in superior clavicle translation (Fig. E) was detected in both groups but more significantly in the conservative group, indicating an inferior reduction of the CC ligaments. Conclusions: To our knowledge, this is the first DSX study reporting the ACJ instabilities 2-5 years post ACJ reconstruction surgery during in-vivo muscle-driven activity. Our preliminary results indicated that the operated side demonstrates increased horizontal and vertical instabilities compared to the uninjured contralateral. Also, ACJ separation remains abnormal, suggesting that the surgery may not fully restore the normative ACJ kinematics mid-to-long term. Furthermore, the ACJ kinematics of the few conservative participants in this study demonstrate extensive ACJ instabilities, potentially implying inferior kinematic outcomes in the conservative group compared to the surgical group. Especially the increased posterior clavicular instability in the conservative group is concerning since it was related to inferior long-term outcomes. While no definitive conclusion can be drawn at this stage due to the sub- optimal sample size , the current findings demonstrate the feasibility of addressing the study aim using the current method, supporting the study hypothesis and providing ample motivation to continue this line of research.

Superior clinical results for early arthroscopic treatment of grade IIIb and V acromioclavicular joint instability compared to delayed operative treatment.

Arthroscopy-assisted cortical fixation devices have been increasingly used in the operative management of both acute and chronic cases of acromioclavicular joint instability (ACJI). It has been hypothesized that delayed surgical management leads to inferior clinical and radiologic outcomes compared to acute treatment. The purpose of this study is to compare clinical and radiologic outcomes, scapula dyskinesia, and failure or revision rates of arthroscopically treated acute and chronic ACJI. This retrospective study of prospectively collected data included all surgically treated patients with grade IIIb and V chronic ACJI between 2013 and 2017, matched 1:1 to a group of acute grade IIIb and V ACJI patients treated during the same time period. Chronic ACJI was defined as delayed surgical treatment >21 days after injury. Chronic cases received an additional hamstring autograft next to the suture pulley systems. Follow-up was obtained at an average of 3.2 years (range: 1.4-6.2). Clinical outcome scores included the Constant-Murley Score (CMS), Taft Score (TF), Nottingham Clavicle Score (NCS), ACJI Score, Sick Scapula Score (SSS), Subjective Shoulder Value (SSV), Subjective Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, and the visual analog scale pain score. Radiologic follow-up was obtained pre- and postoperatively and at final follow-up. The 2-year results were compared to the results of a 1:1 matched-pair group comprising patients who were treated with an acute ACJI during the same period. Thirty-three (80.5%) of 41 chronic ACJI cases were available for follow-up and were compared with 33 matched-pair cases of acute ACJI (of 41). The clinical scores were significantly better in the acute cohort for the CMS (92±8 vs. 88±8, P=.030), ASES (91±13 vs. 85±13, P=.002), SSS (1.4±1.6 vs. 3.4±2.5, P=.0004), NCS (86±13 vs. 81±13, P=.049), TF (9.9±1.9 vs. 9.0±2.1, P=.030), and ACJI (83±13 vs. 75±1, P=.003). In contrast to the chronic cohort, the acute cohort illustrated a significant loss of reduction at follow-up (P=.020). Based on the results of this study, early arthroscopy-assisted operative treatment of grade IIIb and V ACJIs seems superior to delayed surgical intervention of grade IIIb and V ACJIs. Furthermore, an additional autograft loop leads to less loss of reduction compared with suture pulley/suspensory loop fixation standalones.

A Sports Medicine Clinician's Guide to the Diagnosis and Management of Distal Clavicular Osteolysis.

Weightlifting associated shoulder injuries have seen a dramatic rise in the last 20 years. Distal clavicular osteolysis, coined weightlifter's shoulder, is one such condition caused by repetitive microtrauma to the distal clavicle with subsequent, painful development of bony erosions and resorption of the distal clavicle. Diagnosis, treatment, and prevention of this condition can be challenging. In this article, we highlight evidence-based clinical recommendations for the diagnosis and management of distal clavicular osteolysis, including specific considerations for atraumatic and posttraumatic etiologies, to help clinicians better care for their patients. Activity modification and rehabilitation are the mainstays of the initial treatment. Adjuvant treatments, such as injections or surgery, may be required in refractory cases or in certain patient populations. Early recognition and treatment of weightlifter's shoulder is essential to prevent progression to acromioclavicular joint pathology or instability and to allow for continued participation in sport-specific activities.

Superior Clinical Results for Early Arthroscopic Treatment of High-Grade Acromioclavicular Joint Instability Compared to Delayed Operative Treatment

Superior Clinical Results for Early Arthroscopic Treatment of High-Grade Acromioclavicular Joint Instability Compared to Delayed Operative Treatment

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

This study was to compare the two-year clinical and radiological outcomes of an arthroscopic-assisted bidirectional stabilization procedure using single low-profile (LPSB) or double suture button (DSB) techniques with additional percutaneous acromioclavicular (AC) cerclage fixation for patients with acute high-grade AC joint dislocation. This retrospective cohort study compared male patients aged between 18-56 years with acute high-grade AC joint dislocation fixed with either a LPSB or DSB technique. Patients were examined at least 24 months post-surgery. Subjective Shoulder Value (SSV), Taft (TF) and Acromioclavicular Joint Instability scores (ACJI) 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. 28 patients aged 39.2 (LPSB) and 36.4 years (DSB) (p=0.319; CI -2.77 - 8.34) were eligible per cohort. The follow-up was 30.5 (LPSB) and 37.4 months (DSB) (p=0.02; CI -12.73 - -1.08). LPSB patients rated a significantly higher SSV (93.2% vs. 81.9% (DSB); p=0.004). TF and ACJI scores were similar between groups. Coracoclavicular difference markedly decreased from 12 mm to 3 mm for both cohorts (p<0.001). Ossification was identified in over 85% in both cohorts (p=0.160; CI -0.77 - 0.13) and osteoarthritis in 21.4% (LPSB) and 39.3% (DSB) (p=0.150). Persistent DPT was found in around 30% for both cohorts (p=0.561; CI -0.26 - 0.48). The revision rates were 0% (LPSB) and 7% (DSB) (p=0.491). LPSB surgery was shorter (59.7 vs. 71.5 mins [DSB]) (p=0.011). 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 patients satisfaction was in favor of the LPSB technique and no postoperative revision event was observed following this procedure.

Outcomes of Secondary Arthroscopic Distal Clavicle Resection for Shoulders With Symptomatic Acromioclavicular Joint Arthropathy After Isolated Rotator Cuff Repair With Complete Tendon Healing.

Recent meta-analyses have advised against distal clavicle resection (DCR) as an adjuvant procedure during rotator cuff repair (RCR), whether performed routinely or in shoulders diagnosed with symptomatic acromioclavicular joint (ACJ) arthropathy. However, the efficacy of DCR as a secondary procedure in patients with persistent pain attributed to symptomatic ACJ arthropathy remains unknown. To evaluate outcomes of secondary DCR in patients with failed nonoperative treatment of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing. Case series; Level of evidence, 4. Between 2008 and 2018, the senior surgeon performed isolated RCR in 1935 patients, of which 23 (1.2%) presented with ACJ pain and discomfort at ≥12 months after the index RCR, despite complete healing of repaired tendons. Those 23 patients underwent secondary DCR, as ACJ arthropathy was confirmed clinically and radiographically. Clinical assessment before DCR included the Subjective Shoulder Value (SSV) and pain at rest. Clinical assessment at >12 months after DCR included the SSV, pain at rest, Constant-Murley score, range of motion, and satisfaction. Pre- and post-DCR SSV and pain scores were compared. Of the initial cohort, 5 patients did not consent to the use of their data, leaving 18 patients aged 53.3 ± 7.6 years (mean ± SD; range, 39-68 years) for outcome assessment. At a mean follow-up of 7.0 ± 3.1 years after DCR, the SSV significantly improved from 58.7 ± 17.2 to 76.1 ± 20.2 (P < .001), and the pain at rest significantly decreased from 4.7 ± 1.5 to 2.8 ± 1.9 (P < .001). At final follow-up, the Constant-Murley score was 70.2 ± 21.0. Of 18 patients, 15 had none or mild residual pain (0-2; 83%), while 3 had substantial residual pain (5 or 6; 17%). Only 1 of the 3 patients with substantial residual pain had a poor SSV score (20 points) and was against opting for DCR in retrospect. No patient had infections or gross ACJ instability after DCR. Secondary DCR for cases of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing reduced pain in 83% of patients, and 94% were satisfied and would undergo secondary DCR again.

Clinical and anatomical outcomes of isolated coracoclavicular fixation after acromioclavicular joint injury: is it stable enough or is additional horizontal fixation necessary?

Recently, an emphasis has been put on anatomical reduction of acromioclavicular (AC) joint both in vertical and hortizontal planes for management of AC joint injuries due to persisting horizontal instability. Therefore, an additional AC fixation in horizontal plane has been recommended. However, relation between horizontal AC joint instability and clinical outcomes is still controversial. This study aims to evaluate outcomes of isolated coraco-clavicular fixation using arthroscopic assisted single coraco-clavicular tunnel technique in grade III and V AC joint injuries and to investigate the correlation between anatomical and clinical outcomes. This study was conducted with 19 patients with grade III or V AC joint injury. Clinical outcomes included postoperative pain intensity and functional outcomes (Constant Score, American Shoulder and Elbow Surgeons, and Subjective Shoulder Value). Radiological evaluations were performed using radiographs and postoperative computed tomography scans. Degree of initial injury and postoperative stability both on axial and coronal planes were evaluated after radiological assessment. Correlations between anatomical and clinical outcomes were investigated using Pearson's correlation test. At the final follow-up assessment, the mean pain score was 1.8±1.8, mean American Shoulder and Elbow Surgeons score was 81.0±15.4, mean Subjective Shoulder Value was 81.3±19.6, and mean Constant Score was 86.3±14.8. The mean loosening ratio and AC distance were 43.5±30.6% and 4.3±12.4 mm, respectively. No correlation was observed between postoperative anatomical and clinical outcomes (P>.05). Additional AC fixation on horizontal plane is not a prerequisite for all injuries, there is no significant association between horizontal instability and clinical outcomes and indications of an additional AC fixation needs to be determined.

Current concepts in acromioclavicular joint (AC) instability – a proposed treatment algorithm for acute and chronic AC-joint surgery

There exists a vast number of surgical treatment options for acromioclavicular (AC) joint injuries, and the current literature has yet to determine an equivocally superior treatment. AC joint repair has a long history and dates back to the beginning of the twentieth century. Since then, over 150 different techniques have been described, covering open and closed techniques. Low grade injuries such as Type I-II according to the modified Rockwood classification should be treated conservatively, while high-grade injuries (types IV-VI) may be indicated for operative treatment. However, controversy exists if operative treatment is superior to nonoperative treatment, especially in grade III injuries, as functional impairment due to scapular dyskinesia or chronic pain remains concerning following non-operative treatment. Patients with a stable AC joint without overriding of the clavicle and without significant scapular dysfunction (Type IIIA) may benefit from non-interventional approaches, in contrast to patients with overriding of the clavicle and therapy-resistant scapular dysfunction (Type IIIB). If these patients are considered non-responders to a conservative approach, an anatomic AC joint reconstruction using a hybrid technique should be considered. In chronic AC joint injuries, surgery is indicated after failed nonoperative treatment of 3 to 6 months. Anatomic AC joint reconstruction techniques along with biologic augmentation (e.g. Hybrid techniques, suture fixation) should be considered for chronic high-grade instabilities, accounting for the lack of intrinsic healing and scar-forming potential of the ligamentous tissue in the chronic setting. However, complication and clinical failure rates remain high, which may be a result of technical failures or persistent horizontal and rotational instability. Future research should focus on addressing horizontal and rotational instability, to restore native physiological and biomechanical properties of the AC joint.

Wrestler's Shoulder

History: 14 year old male with left shoulder pain after injury during wrestling meet. He was participating in wrestling meet 2 days prior when he was thrown to the mat. He landed on his left elbow and felt immediate pain in his shoulder, was unable to move the shoulder due to pain. He has decreased range of motion and weakness with shoulder movement, pain with moving, lifting, and sleeping. Denies any radiating pain, numbness/tingling or history of prior shoulder injuries. Physical Examination: No obvious deformity, no bony tenderness to palpation. Active ROM is forward flexion to 140 degrees with pain, abduction to 120 degrees with pain, external rotation with elbow at side to 20 degrees with pain, internal rotation to L3 with pain. Passive ROM full in all directions. The belly-press test, lift-off tests are abnormal, and the bear hug test shows weakness. Strength 4/5 of the infraspinatus, 4/5 of supraspinatus with pain. Neer/Hawkins, Obrien's signs negative. Neurovascularly intact in the bilateral upper extremities. Differential Diagnosis: Humeral, glenoid or scapular fracture, Rotator cuff tear, AC joint dislocation Final/Working Diagnosis: Fracture to base of coracoid process, Avulsion fracture of lesser tuberosity of humerus Tests and Results: Xray L shoulder: Humeral head high-riding. Widening of the left coracoid on axillary view. Widening of the AC joint. Humeral physes open, normal and symmetric compared to contralateral shoulder. MRI L shoulder: Minimally displaced fracture through base of the coracoid process, medially-displaced, lesser tuberosity physeal fracture. Hemarthrosis of the glenohumeral joint. Edema within subscapularis muscle belly. No rotator cuff full-thickness tears. Treatment and Outcomes: Athlete was referred to an Orthopaedic surgeon and underwent lesser tuberosity avulsion repair, coracoid ORIF, and closed treatment of AC joint instability. Patient immobilized in a sling for 6 weeks post-operatively. Passive ROM was initiated at 2 weeks post-operatively. Active ROM was allowed at 6 weeks progressing to full active elevation. Athlete was allowed to begin weight-lifting as tolerated, running and non-contact practice at 8 weeks. Post-operative course was uncomplicated and the athlete was cleared for full return at 12 weeks post-operatively.

The Role of the Trapezius in Stabilization of the Acromioclavicular Joint: A Biomechanical Evaluation.

Background:Acromioclavicular joint (ACJ) injuries are common, and many are adequately treated nonoperatively. Biomechanical studies have mainly focused on static ligamentous stabilizers. Few studies have quantified ACJ stabilization provided by the trapezius.Purpose/Hypothesis:To elucidate the stabilization provided by the trapezius to the ACJ during scapular internal and external rotation (protraction and retraction). It was hypothesized that sequential trapezial resection would result in increasing ACJ instability.Study Design:Controlled laboratory study.Methods:A biomechanical approach was pursued, with 10 cadaveric shoulders with the trapezius anatomically force loaded to normal. The trapezius was then serially transected over 8 trials, which alternated between clavicular defects (CD) and scapular defects (SD); each sequential defect consisted of 25% of the clavicular or scapular trapezial attachment. After each defect, specimens were tested with angle-controlled scapular internal and external rotation (12°) with rotary torque measurements to evaluate ACJ stability.Results:The mean resistance in rotary torque for 12° of scapular internal rotation (protraction) with native specimens was 7.0 ± 2.0 N·m. Overall, internal rotation demonstrated a significant decrease in ACJ stability with trapezial injury (P < .001). Eight sequential defects resulted in the following significant percentage decreases in rotary torque from native internal rotation: 1.5% (25% CD; 0% SD), 5.6% (25% CD; 25% SD), 5.1% (50% CD; 25% SD), 6.5% (50% CD; 50% SD), 3.8% (75% CD; 50% SD), 7.1% (75% CD; 75% SD), 6.7% (100% CD; 75% SD), and 12.3% (100% CD 100% SD) (P < .001). The mean resistance in rotary torque for 12° of scapular external rotation (retraction) with native specimens was 7.1 ± 1.7 N·m. External rotation did not demonstrate a significant decrease in ACJ stability with trapezial injury (P = .596). The 8 sequential defects resulted in decreases in rotary torque from native external rotation of 0%, 3.8%, 4.0%, 3.2%, 3.5%, 3.4%, 4.2%, and 0.7%.Conclusion:Trapezial injury resulted in increased instability in the setting of scapular internal rotation (protraction) of the ACJ.Clinical Relevance:These findings validate the inclusion of deltotrapezial fascial injury consideration in the modified Rockwood classification system. Repair of the trapezial insertion on the ACJ may provide improved outcomes in the setting of ACJ reconstruction.

Results of Surgical Treatment of Patients with Chronic Acromioclavicular Joint Dislocations

Relevance. Treatment of chronic acromioclavicular joint dislocations remains a controversial issue and ranges from conservative treatment to extensive reconstruction.&#x0D; Objective: to compare clinical and radiographic results of surgical treatment of patients with chronic acromioclavicular joint dislocation.&#x0D; Materials and Methods. A retrospective analysis of 41 patients with chronic acromioclavicular joint dislocation was performed (time from the injury was more than 3 weeks). The patients were divided into two groups: group I (19 patients, 46.3%), which underwent arthroscopically assisted dynamic type of acromioclavicular joint dislocation stabilization with acromioclavicular and coracoclavicular ligaments augmentation, and group II (22 patients, 53.7%), which underwent fixation of acromioclavicular joint dislocation with Hook-plate and acromioclavicular and coracoclavicular ligaments augmentation. The mean age at surgery was 34.1±11.2 years (range 18-70 years). Most of the patients were males – 36 patients (87.8%). Clinical outcomes were assessed using the Oxford Shoulder Score, Constant – Murley Score, and Acromioclavicular Joint Instability Scoring System.&#x0D; Results. The mean Oxford Shoulder score before surgical treatment was 31.5±7.7 points and 33.3±4.2 points (p=0.347), and at the final follow-up 46±2.6 points and 46.1±1.6 points – in group I and group II, respectively. The mean Constant – Murley score before surgical treatment was 68.9±12.4 points and 69.7±14.5 points (p=0.863), and at the final follow-up 94.2±7.7 points and 96.5±3.9 points (p=0.291). The mean Acromioclavicular Joint Instability Scoring System score before surgical treatment was 31.3±9.5 points and 25.1±8.2 points (p=0.087), and at the final follow-up 79.9±16.7 points and 75.7±9.1 points (p=0.422), respectively. Concomitant intra-articular injuries of the shoulder joint were diagnosed in 68.4% of patients; the most common injuries were SLAP injury and long head of biceps tendonitis. Complications of treatment were noted in both groups, but there were no complications that would require additional reconstructive.&#x0D; Conclusions. Arthroscopic assisted dynamic fixation techniques or open fixation techniques with a specialized plate in combination with the reconstruction of acromioclavicular ligaments and coracoclavicular ligaments by tendon autografts provides good long-term functional results.

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

To evaluate the clinical outcome of lateral clavicle malunion treated with all-arthroscopic coracoclavicular (CC) stabilization. Retrospective, case series. Department of hand and upper extremity surgery, university hospital center. Forty-five patients with unstable and displaced lateral clavicle fracture treated between January 2015 and August 2019 were included in the study. Closed reduction and arthroscopic CC stabilization using cortical buttons. 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. 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). 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. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive reconstruction of acute acromioclavicular joint injuries using the TwinBridge button system

IntroductionAcute 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 methodsFrom 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.ResultsAll 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.ConclusionsWhen 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.

Clinical and Radiological Outcomes of Closed-Loop, Double Button, Coracoclavicular Fixation for Extralateral (Neer Type IIC) Fractures of the Distal Clavicle.

Background: The distal end of the clavicle accounts for 10-28% of all clavicle fractures of which 52.8% are considered displaced and require internal fixation due to their high percentage of non-union. Numerous surgical techniques have been described for the well-known Neer types IIA, IIB, and V. Still, the literature is scarce for the rare “extralateral” (type IIC) fracture where the fracture line is located lateral to the completely torn coracoclavicular (CC) ligaments; such small fractures are sometimes not amenable for standard locking plate fixation.Methods: We present a series of seven patients treated surgically with closed-looped double button CC stabilization via an open approach. There were four males and three females with a mean age of 31 years (range: 19-46 years). The mechanism of injury was a motor vehicle accident in four cases and a fall from height in three cases. The average time from injury to surgery was 2.7 ± 1.3 days and the average follow-up period was 25.7 months (range: 16-48 months). A custom-made, closed-looped, double button device was made using the ProCinch Adjustable Cortical Fixation for anterior cruciate ligament (ACL) (Stryker, Kalamazoo, Michigan) and another standard or slotted button. The fracture was reduced anatomically and the device was tightened and secured with five to six knots. In two cases, additional interfragmentary sutures were used for extra stability. Postoperatively, the arm was immobilized in a simple sling for four weeks; passive assisted elevation up to 90 degrees was allowed from the second postoperative week, followed by active elevation after the sixth postoperative week. Radiological outcomes (bony union, loss of reduction, implant mispositioning, or subsidence of buttons) were assessed using serial plain radiographs. The Constant score (CS) and the Acromioclavicular Joint Instability Score (AJIS) were used for the final clinical evaluation, at least one year postoperatively.Results: Bony union was achieved in all patients at a mean time of 2.7 months (range: 2.5-3.6 months). No cases of delayed union, loss of reduction, button migration, or subsidence were noted. The mean CS was 96.6 ± 3.4 and the mean AJIS score was 94.1 ± 4.7 in a mean follow-up period of 25.7 months (range: 16-48 months). One patient developed a hypertrophic scar and another had mild skin irritation by the suture knots; no other complications were noted except for one patient who developed an early superficial skin infection managed with antibiotics and debridement under local anesthesia. Four patients who participated in sports before injury were able to regain almost full activity seven to nine months after the operation. All were satisfied with the final result. Two patients showed ossification of the CC ligaments with no significant clinical implications.Conclusions: Although we retrospectively reviewed a small series of patients, we were able to demonstrate a complete rate of fracture union and excellent clinical outcomes with no major complications. Type IIC distal clavicle fractures are rare and require special attention in terms of reduction and optimal fixation. Open CC fixation with closed-looped double buttons is a relatively easy and reproducible technique. We advocate the readjustment of Neer’s classification, including “extralateral” fractures as a IIC subtype.

Are Patient-Reported Outcome Scores a Reasonable Substitute for Clinical Follow-up After Surgically Managed Acromioclavicular Joint Injuries?

Background:Various clinical outcome scores have been described to evaluate postoperative shoulder function after operatively treated acromioclavicular joint (ACJ) instability. Clinical outcome scores can be divided between patient-reported outcome measures (PROMs) and examiner-dependent outcome measures (EDOMs) after a clinical examination by a physician. The correlation between PROMs and EDOMs, and thus their interchangeability with regard to operatively treated ACJ instability, has not yet been evaluated.Purpose:To investigate whether PROMs are a reasonable substitute for EDOMs. Correlations between global shoulder (GS) and ACJ-specific outcome measures were also investigated.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:Included in this study were 131 consecutive patients with operatively treated ACJ instability between 2011 and 2017. Postoperative shoulder function was measured using PROMs, including the Subjective Shoulder Value (SSV), Subjective Shoulder Test, and Nottingham Clavicle Score (NCS), and EDOMs, including the Constant-Murley score (CMS), Taft score, ACJ instability (ACJI) score, and SICK Scapula Score (SSS). Associations between PROM and EDOM scores were calculated using the Pearson and Spearman correlation coefficients for linear and nonlinear variables, respectively, and were interpreted using the Cohen classification. The scores were further stratified into GS versus ACJ-specific measures.Results:A strong correlation was observed between several PROMs and EDOMs (CMS vs SSV [r = 0.59; P = .02] and CMS vs NCS [r = 0.79; P ≤ .001]) and between several GS and ACJ-specific scores (CMS vs NCS; CMS vs ACJI [rs = 0.69; P < .001]; and CMS vs SSS [r = –0.68; P < .001]).Conclusion:Based on the results of this study, PROMs such as the SSV (a GS measure) and the NCS (an ACJ-specific measure) can substitute for EDOMs.Clinical Relevance:PROMs that can be substituted for EDOMs can enable the conduct of clinical studies in circumstances in which in-person clinical follow-up of the patient by a physician is not possible.