Acromioclavicular Joint Separation Research Articles

High Vertical and Horizontal Stability at Short-Term Follow-Up After an All-Endoscopic Double Cerclage Endobutton Technique for Acute Acromioclavicular Joint Separations

PurposeThe aim of this study was to evaluate the clinical and radiological outcomes in the treatment of acute acromioclavicular joint (ACJ) separations using an all-endoscopic double cerclage endobutton technique compared to an arthroscopic-assisted single bundle endobutton technique. The secondary aim was to analyze the complication, failure and revision rate of both procedures. Material and methodsAll patients with acute ACJ separations Rockwood IIIB and V who were operated on using an all-endoscopic double-cerclage technique (2019-2022) or an arthroscopic-assisted single bundle technique (2017-2019) were included. The follow-up period was at least 12 months. Clinical and radiographic assessment was performed at follow-up. Complications, failures, and the revision rate were also investigated. ResultsTwenty-eight patients (14 double cerclage group, 14 single bundle group, all male) with an average age of 37 (IQR: 15) years were available for follow-up after 45 (IQR: 38) months. The median time between trauma and surgery was 7 (IQR: 8) days. Very good clinical results without significant differences were observed in both groups (Constant score: 94 (IQR: 12) vs. 95 (IQR: 15), p=0.427, ACJ Instability score: 95 (IQR: 11) vs 87 (IQR: 22), p=0.210). All patients returned to sport, with an average sports level of 95% compared to the preoperative status. The single bundle group showed significantly increased anteroposterior instability (6 vs. 0, p=0.006). A total of 5 complications occurred (2 vs. 3), leading to 1 revision surgery in each group. ConclusionExcellent clinical results and high vertical and horizontal stability can be achieved with the all-endoscopic double cerclage technique. Horizontal instability occurred significantly more frequently with the single bundle technique. The prolonged operation time in the double cerclage group had no negative impact on postoperative outcomes, including complication and failure rates, and a learning curve to reduce this prolonged operative time should be considered. Level of EvidenceIII, retrospective comparative clinical series

Acromioclavicular joint separation: Controversies and treatment algorithm.

In this article, we present an uptodate outline of acromioclavicular (AC) joint separation. A clear understanding of acromioclavicular joint injury in terms of the mechanism of injury, clinical picture, diagnostic imaging, and most updated surgical techniques used for the treatment can provide the best care for those patients. This article describes updated treatment strategies for AC separation, including type III AC separation which is known most controversial. Finally, we present a proposed treatment algorithm that can aid in the treatment of AC separation from the most updated evidence.

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 .

3D C-arm navigated acromioclavicular joint stabilization

IntroductionSurgical 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 methodsThe 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.ResultsAll 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.ConclusionIntraoperative 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.

Complications after operative treatment of high-grade acromioclavicular injuries.

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. 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. 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. 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.

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.

Paper 59: No Difference in Post-Operative Outcomes for High-Grade Acromioclavicular Joint Surgery Performed Acutely vs Chronically

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 (&lt;6 weeks) vs chronically (&gt;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&lt;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 (&lt;6 weeks) had similar post-operative outcomes to patients who underwent surgery chronically (&gt;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. [Table: see text][Table: see text]

Nottingham Klavikula Skorunun Türk Populasyonunda Geçerliliği ve Doğrulanması

Aim: The aim of this study was to evaluate the validation and verification of the Nottingham Clavicle Score (NCS) in the Turkish population. Methods: Sixty-eight patients (12 females, 56 males; mean age: 37.1±13.3 years) who underwent surgery due to clavicle fracture or acromioclavicular separation were included in the study. The Turkish version of the NCS (NCS-Tr) was designed in accordance with the stages recommended by Beaton et al. Each patient completed the NCS-Tr twice at 7 to 10-day intervals to evaluate the test-retest reliability based on the interrater correlation coefficient, and Cronbach’s alpha was evaluated for internal consistency. Additionally, the Oxford Shoulder Score (OSS), Disabilities of the Arm, Shoulder, and Hand (DASH), Constant-Murley Score (CMS), and Short Form-36 (SF-36) Health Survey tests were completed by each participant to assess the correlation with the NCS-Tr. Results: The main score of the NCS-Tr was 79.71 ± 20.37. The other mean scores of CMS, OSS, and DASH were 84.14 ± 21.47, 38.34 ± 12.43, and 17.84 ± 22.47 respectively. The translation and adaptation of the NCS-Tr for a Turkish context required no major cultural adaptation. Internal consistency was high (Cronbach’s alpha: 0.933). Test-retest reproducibility was excellent (q=0.941, p&amp;lt;0.001). Conclusion: The NCS-Tr is a valid, reliable, shoulder-specific scale in the assessment of patient-reported outcome measures for the functional assessment of Turkish patients undergoing surgery due to clavicle fractures or acromioclavicular joint separation.

Arthroscopic-Assisted Coracoclavicular and Acromioclavicular Ligament Reconstruction for Chronic AC Joint Separation

Background: Management of acromioclavicular joint (ACJ) separations depends on the type, chronicity of injury, and patient demographics. Indications: Coracoclavicular and acromioclavicular ligament reconstruction may be indicated for patients with chronic type 3 ACJ separation who have failed conservative treatment. We describe an arthroscopic-assisted approach to facilitate graft passage around the coracoid. Technique: Patients are placed in a beach chair position. A longitudinal incision at the midline of the distal clavicle is utilized for access to the ACJ, the distal clavicle, and the coracoid. The anterior, posterior, and undersurface of the distal clavicle are exposed. A standard posterior viewing and anterolateral working portals are created. A shuttling suture is passed arthroscopically and used to pass allograft and nonbiologic augmentation around the coracoid. The nonbiologic sutures are passed through a singular hole in the distal clavicle and secured with a DogBone button. The allograft is wrapped around the clavicle to recreate the coracoclavicular ligaments and secured with sutures. The ACJ capsule is reconstructed by suturing the posterior/medial limb, which is kept long, to the capsule and periosteum. Meticulous, layered closure is performed with particular attention to closing the deltotrapezial fascia. Results: A postoperative x-ray at 2 weeks and 6 months are obtained to confirm proper positioning. The sling is discontinued at 6 weeks, and supervised physical therapy is initiated. At 6 months, patients are typically cleared to full unrestricted activity. Discussion/Conclusion: Arthroscopic-assisted coracoclavicular and acromioclavicular ligament reconstruction in patients with chronic type 3 ACJ separation who fail conservative management can have excellent outcomes. The use of arthroscopic assistance may ease the passage of graft and nonbiologic suture around the coracoid. A 70° scope is helpful for coracoid visualization, and biologic reconstruction of the ligament with tendon graft with suture augmentation in chronic cases is vital in achieving a good outcome. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Conservative treatment of Rockwood type III acromioclavicular joint separation: a randomized controlled trial sling vs. brace

Management of Rockwood III acromioclavicular joint separations is a matter of ongoing debate, with nonoperative treatment being favored in recent literature. The aim of this study is to compare clinical and radiological outcomes of nonoperative treatment with a brace, which elicits a direct reduction force to the distal clavicle, to a sling. We hypothesized the brace might yield in better acromioclavicular joint (ACJ) reduction and cosmesis. In this dual center prospective randomized controlled trial, all patients sustaining an acromioclavicular joint separation Rockwood III between July 2017 and August 2020 were included. Patients with previous ipsi- or contralateral ACJ injury or surgery were excluded. Randomization occurred in the emergency department to either the sling or brace group. Patients were followed up at 1, 6, and 12 weeks. Patient-reported outcome measures included subjective shoulder value (SSV) and American Shoulder and Elbow Surgeons (ASES) score at each follow-up and Constant Score at 6 and 12 weeks. Vertical distal clavicle displacement was assessed on bilateral non-weighted panoramic anteroposterior radiographs using coracoclavicular (CC) distance to calculate the CC-index. Thirty-five consecutive patients were included across the 2 sites, 18 (all male) in the brace and 17 (14 male) in the sling group. Baseline characteristics did not differ significantly between groups, the average age was 40 years, and body mass index 25.5 kg/m2. Analysis revealed no statistical difference in CC-index between groups at the time of injury, 6 weeks and 12 weeks postinjury (P=.39, P=.11, and P=.21). SSV improved from 30 and 35 postinjury to 81 and 84 at 12 weeks in the sling and brace group, respectively (P=.59). ASES improved from 48 and 38 to 82 and 83, respectively (P=.84). Similarly, Constant Score improved from 64 and 67 to 82 and 81, respectively (P=.90). One patient in the brace group underwent ACJ stabilization with hamstring autograft at 4 months due to persistent pain. This randomized controlled trial shows no statistically significant difference between the brace and sling group in clinical (SSV, ASES, Constant Score) or radiological (CC-index) outcomes after conservative treatment of Rockwood III injuries.

Physeal injuries of the clavicle: pediatric counterparts to adult acromioclavicular and sternoclavicular joint separations.

The epiphyses at the medial and lateral ends of the clavicle are small, ossify relatively late, and may not fuse until early adulthood. Because of this unique anatomy, pediatric and young adult injuries that involve the clavicle often differ from the patterns typically seen in older adults. Clavicular trauma that affects the acromioclavicular joint laterally or sternoclavicular joint medially often results in a physeal fracture and as such, can go unrecognized or be mistaken for a joint dislocation. Radiographic assessment is challenging, particularly when the epiphysis is not yet ossified. However, MR imaging allows for visualization of the cartilage, periosteum and perichondrium, and ligaments of the affected joints. Lateral clavicle physeal injuries can be categorized by the Dameron and Rockwood system, the pediatric correlate to the Rockwood classification of adult acromioclavicular joint injuries. Medial clavicle physeal fractures, similar to adult sternoclavicular joint dislocations, may result in anterior or posterior displacement. Because of their great ability to heal and remodel, clavicular physeal fractures respond better to conservative management than true acromioclavicular or sternoclavicular joint dislocations. Therefore, it is essential to recognize the true nature of these injuries, as there are implications for successful treatment and appropriate prognosis.

Open Acromioclavicular Repair With a Suture Cerclage Tensioning System: A Case Series.

Introduction Numerous 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 technique An 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. Methods From 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 CCdistance was measured to determine the integrity of the all-suture cerclage repair. Results Of 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. Conclusion Overall, 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.

Acromioclavicular Joint Problem in Athletes

Introduction: Acromioclavicular (AC) joint separations account for 12% of all shoulder injuries. People doing high-energy physical activities such as athletes are at risk for AC joint separation. The mechanism of injury could be direct or indirect. Direct mechanism involves a direct blow to the AC and coracoclavicular (CC) ligaments. Indirect mechanism happens when the injury force hits the AC joint indirectly, involving axial compression, as seen in a fall with an extended arm, where caput humeri is pressed against the acromion. The purpose of this paper is to elaborate on AC joint problems in athletes by reviewing literatures. Review: Patients with AC joint injury will exert complaints of pain and be unwilling to lift the affected arm, implying mobility function impairment. Signs such as skin abrasions and bruises can be found during inspection. A prominent distal clavicle is a pathognomonic sign of dislocation of the AC joint. A well-known classification for AC joint separations, Rockwood classification, divides the separations into six types. The classification helps determine different managements and prognoses for each of the AC joint separation types. Athletes should be treated in consideration of their position in the sports season. For athletes in season, pain should be treated as the priority. Absolute indications for surgical management are then identified to help determine the athlete’s return-to-play capability. For out-of-season athletes with AC injury, look for absolute or relative indications for operative management. If there is no indication, plan for rehabilitation. But if there are some indications, either absolute or relative, plan for surgery immediately. Complaints of pain and functional disabilities such as motion should be carefully assessed and managed. To determine suitable management, the injury should be classified properly. Type I and II injuries are treated with nonsurgical management. For type IV and VI injuries, surgical intervention is needed. AC joint separation Rockwood type III and V both had complete AC and CC ligament tear but repair is adequate for acute type III AC injury while reconstruction is needed for type V AC injury. Conclusion: AC joint separations should be treated as joints, not as bones where compressions are applied therefore limiting movements. Repair and reconstruction indications should be properly assessed on patients to ensure functions returned to their pre-injury state which is important for athletes’ return to sports.

Coracoid process transfer and distal clavicle resection for chronic acromioclavicular separation.

Dewar's procedure for transferring the coracoid process with the short head of biceps and coracobrachialis was reported in 1965 for treatment of both acute and chronic acromioclavicular (AC) joint separation, but little contemporary literature exists around the procedure. We report the clinical results of coracoid process transfer with excision of the lateral end of the clavicle for chronic AC joint separation. Fifty-one patients (39 men and 12 women, mean age 46±16 years) were included in the study. Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons and the Japanese Orthopaedic Association scores, as well as by measuring active range of motion in the shoulder, before-after (minimum follow-up time of 24 months [27±3 months]) surgery. Plain radiographs were used to examine stability of the AC joint and bone union of the graft. The mean American Shoulder and Elbow Surgeons and Japanese Orthopaedic Association scores increased (from 61±14 to 91±6, and from 54±9 to 89±8, respectively) at the time of final follow-up. There were no differences in active elevation and external rotation between before-after operation. Six patients whose grafts were fractured or displaced showed complete or partial loss of reduction of the AC joint. By transferring the coracoid process, the AC joint regained stability after chronic joint separation. Although potential complications related to the graft still need to be addressed, Dewar's procedure and lateral clavicle resection could be a reliable treatment of chronic AC joint separation.

Acromioclavicular joint separation: Retrospective study of non-operative and surgical treatment in 38 patients with grade III or higher injuries and a minimum follow-up of 1 year

IntroductionAcromioclavicular (AC) joint separation is a common shoulder injury. When the injury is graded as type III or higher in the Rockwood classification, surgical treatment can be proposed. However, an increasing number of practitioners are shifting back to conservative treatment as it is associated with fewer complications and seemingly close functional outcomes. The aim of our study was to evaluate the functional recovery of operated and non-operated patients with grade III or higher AC joint injuries. Secondarily, the reliability and relevance of the Rockwood classification was evaluated within and between raters. Materials and methodsWe did a retrospective two-center study of 38 patients treated between 2014 and 2020. The clinical evaluation involved various functional outcome scores (Constant, QuickDASH, ASES, UCLA, SSV, STT) and a pain assessment (VAS). Return to sports and to work was also documented. The radiological evaluation consisted of Zanca AP and lateral axillary views immediately after the injury and at each radiographic follow-up visit until the final visit. An intra- and inter-rater analysis was also done for the Rockwood classification. ResultsThere was no significant difference in the functional scores (Constant score surgery group=91, nonoperative group=83; p=0.09) or the pain on VAS at the final assessment. Return to work and to sports was significantly faster in patients treated non-operatively. No complication was found in the non-operated patients, while nine of the operated patients suffered a complication. The inter-rater reliability of the Rockwood classification was found to be poor (kappa=0.08) to fair (kappa=0.35), while the intra-rater reliability was moderate (kappa=0.6) to good (kappa=0.63). Discussion/conclusionNo matter which treatment is used, the functional outcomes and patient satisfaction level a minimum of 1 year after the injury appear to be identical. Thus, surgery should be only for patients whose AC joint is painful 7 days after the injury (VAS>7) and whose function has not improved. For young and athletic patients or for patients who simply want to regain nearly normal function, it is important to remember that the time to return to work and sports is longer with surgical management and to take into consideration the potential postoperative complications. While none of the patients who received the non-operative treatment required a secondary stabilizing surgery, this is a possible recourse. Level of evidenceIII.

Addition of Allograft and Acromioclavicular Cerclage Improves Outcomes of Arthroscopic-Assisted Reconstruction of Acromioclavicular Separation With a Single Coracoclavicular Tunnel.

ObjectiveThe purpose of this study was to prospectively evaluate the functional outcome and complications of unstable acromioclavicular (AC) joint separations repaired with a single coracoclavicular tunnel utilizing an arthroscopic-assisted curved button technique.MethodsThirty-five patients with a minimum of 12 months follow-up underwent arthroscopic-assisted AC joint reconstruction with suspensory button and 2 mm suture tape fixation using 3 mm tunnels. Functional outcome scores were analyzed preoperatively and at final follow-up with all complications noted.ResultsComparing preoperative to postoperative values, all functional outcome scores improved. Three of the 16 (19%) patients that had a supplementary graft looped around the undersurface of the coracoid demonstrated loss of reduction compared to eight of the 19 (42%) that were treated with button and suture fixation alone (p = .138). No loss of reduction occurred in the subset of patients with AC joint supplementation. One (3%) patient sustained a distal clavicle fracture.ConclusionArthroscopic-assisted AC joint reconstruction with a suspensory button construct demonstrates improved clinical outcomes with high patient satisfaction. While loss reduction remains problematic, smaller bone tunnels appear to lead to a low rate of iatrogenic fractures. The addition of a free tendon graft, as well as AC cerclage, appears to minimize loss of reduction.

Classification, Diagnosis, And Treatments for Acromioclavicular Joint Injury

Acromioclavicular (AC) joint separation is a frequent shoulder injury with increasing office working hours and sports. This research examines the classification of grades, as well as the causes, diagnostic procedures, and therapies associated with each grade. Results show that young and energetic men, as well as people who regularly participate in contact sports, are high-risk groups for this injury. X-rays, bone scans, positive compression, and horizontal adduction tests are among the diagnostic and examination methods available. The six-degree classification system developed by Rockwood is the most widely used classification system for AC joint injury. A minor sprain of the AC ligament is a Type I injury. Type II injuries are characterized by a torn AC ligament and sprained CC ligaments, and they typically result in more pain and swelling than Type I injuries. Types III-VI are the most serious injuries, with a burst AC ligament, CC ligament, and joint capsule in every case. The location of the damage, as well as the treatment choices, differ by type. Non-surgical treatments are indicated for Types I-III injuries. Surgical procedures are advised for Types IV-VI injuries. It should be mentioned that the treatment plan should be tailored to the individual's needs, with the negative effects taken into account.

Characteristics And Comparison of Tossy and Rockwood Classifications for Acromioclavicular Joint Separations

Acromioclavicular joint (AC joint) is one of the four articulations that make up the shoulder joint. Injuries related to the shoulder joint often damage the AC joint. Since AC joint separation is usually caused by external force applied to the shoulder, it is one of the most familiar shoulder injuries in sports, especially sports with body contact such as ice hockey, football, and basketball. As the force that causes injury varies, there are different grades of severity of the AC joint separation. This study focuses on two main classifications (Tossy classification and Rockwood classification) of the severity of the AC joint separation and discusses the corresponding treatments as well as the criticisms of each classification. Tossy three-degree classification is straightforward that could be categorized quickly after diagnosis. Grade 1 requires the use of a well-designed sling, Grade 2 needs a specific treatment plan, and Grade 3 requires open surgeries. Rockwood's six-type classification is more detailed than the three-degree classification and represents the complicated pathophysiology. Types I and II are recommended for non-operative treatments, Type III should adopt non-operative treatment firstly, and then the operative management. Types IV, V, and VI need surgical treatments.

Clinical and Patient-Reported Outcomes for Acute Acromioclavicular Joint Fixation are Similar With or Without Allograft Augmentation

PurposeTo compare functional outcomes, complications, and revision rates between allograft reconstruction and graftless fixation techniques for the treatment of Rockwood grades III-V acute acromioclavicular (AC) joint separation.MethodsPatients who underwent graftless or allograft surgery acutely (≤6 weeks from injury) for Rockwood type III-V AC joint separations from 2012 to 2018 were retrospectively reviewed. Clinic notes and operative reports were identified to confirm the surgical technique and presence of complications including revision, infection, and fracture. In addition, postoperative radiographs were assessed to determine any instances of loss of adequate reduction, and several patient-reported outcomes were collected.ResultsIn total, 115 patients (52 allograft, 63 graftless) were included in this study with a mean follow-up of 3.8 ± 2.5 years. There were no differences between allograft and graftless patients regarding rates of loss of reduction >5 mm (11.1% graftless vs 21.2% allograft), revision (3.2% vs 1.9%), infection (1.6% vs 3.9%), fracture (3.2% vs 7.7%), or total complication (7.9% vs 9.6%) rates (all P > .05). Patient-reported outcome measures also did not significantly differ between groups. Multivariate analysis found that increased time from injury to repair and increased Rockwood injury grade (grades IV and V) were associated with increased CC distance at postoperative follow-up (P = .008, .050, and .047, respectively).ConclusionMultivariate analysis found that patients who underwent acute AC joint fixation without allograft augmentation had similar functional outcomes, complications, and revision rates compared with patients who underwent AC joint reconstruction with allograft.Level of EvidenceLevel III, retrospective comparative study.

Poster 147: Operative Treatment of Acromioclavicular Injuries in the Military: Trends and Complications

Objectives:To identify the demographics and characteristics of operative acromioclavicular joint separations, as well as characterize reconstruction techniques and associated complications.Methods:The United States Military Health System Data Repository was queried for patients with a Current Procedural Terminology (CPT) code for coracoclavicular ligament reconstruction between October 2013 and March 2020. Patient demographics, radiology and operative reports, and clinical notes were reviewed to characterize reconstruction techniques and associated postoperative complications.Results:A total of 956 coracoclavicular ligament reconstructions (896 primary repairs or reconstructions, 60 revision reconstructions) were performed between October 2013 and March 2020. The 896 primary coracoclavicular ligament reconstructions were indicated for a range of acromioclavicular joint separation severities: three grade two separations, 392 grade three separations, 48 grade four separations, and 386 grade 5 separations; the remaining 67 patients did not have a definitive injury grade defined by the treating surgeon. Of the primary procedures, 356 were performed acutely within 6 weeks of injury, while 538 were performed greater than 6 weeks after injury. Two hundred and twenty eight primary procedures were categorized as repairs, while 652 were categorized as reconstructions utilizing a graft. Following these procedures, there were 104 major complications requiring return to the operating room, including 48 symptomatic failures requiring revision, 18 fractures of the clavicle or coracoid, 25 deep surgical site infections and 9 cases of symptomatic hardware requiring removal of hardware, and 4 cases of adhesive capsulitis requiring manipulation under anesthesia. There were 160 minor postoperative complications, including 5 non-operative fractures of the clavicle or coracoid, 16 superficial surgical site infections, 7 cases of non-operative adhesive capsulitis, 57 cases of neuropathy, 1 deep venous thrombosis, and 74 cases of persistent acromioclavicular joint pain. There were no significant differences in complication rates between injury grade, acute versus chronic treatment, repair versus reconstruction, or suspensory versus non-suspensory technique. The rate of major complications was 1.8 per 100 person-years and the rate of minor complications was 2.77 per 100 person-years. The overall complication rate was 4.57 per 100 person-years. At the conclusion of the acromioclavicular joint separation care, 60 service members necessitated medical separation from the military.Conclusions:Coracoclavicular ligament reconstruction is a relatively common and safe procedure in a physically active population. The rate of major complication was 1.8 per 100 person-years, while the overall complication rate in our series was 4.57 complications per 100 person-years. Complications are rare, however, when they occur, they frequently require one or more secondary surgeries to treat.