Acromioclavicular Reconstruction Research Articles

Use of the pectoralis minor and coracoacromial ligament for a biplanar coracoclavicular and acromioclavicular reconstruction: A cadaveric feasibility study.

The aim of this study was to evaluate the feasibility of a novel technique that focuses on vertical and horizontal stabilization of the acromioclavicular joint using two local autologous grafts, the pectoralis minor (Pm) and the coracoacromial ligament (CAL). Ten fresh-frozen shoulder cadaveric pieces were dissected. Length and width of the Pm and CAL were measured in their anatomical position and anatomical variants were noted. The Pm tendon was harvested at the myothendinous junction keeping the insertion at the coracoid process. The CAL was detached from the coracoid process keeping the acromial insertion. The free limbs of both grafts were prepared with the Krackow technique and the Arthrex SpeedWhip technique, respectively. The primary coracoclavicular reduction and fixation were with the button system or with two subcoracoid ultrahigh-strength suture cerclage through and around the clavicle. The Pm graft was fixed inside a clavicular tunnel by a cortical button and the CAL was transferred and fixed to the lateral clavicle using a knotless anchor or intramedullary when lateral clavicle resection was performed. The median length of the Pm was 50 mm (interquartile range [IQR]: 50-54), and the median length of the CAL was 36.5 mm (IQR 34-40) which decreased by 15% and 23% once were prepared with the Krackow and Arthrex SpeedWhip techniques to 44.5 mm (IQR: 30-65) and 30 mm (IQR: 22-32), respectively. The diameter of the prepared Pm graft was 5 mm (IQR: 4.5-6) and the CAL graft 5.5 mm (5-6). All grafts were able to reach the fixation points. The procedure was feasible in 100% of the cases. A biplanar reconstruction using autologous Pm and CAL appears feasible in restoring the acromioclavicular joint stability. Level IV. Basic science, anatomy, cadaveric dissection.

Tendon graft through the coracoid tunnel versus under the coracoid for coracoclavicular/acromioclavicular reconstruction shows no difference in radiographic or patient-reported outcomes.

The purpose of this prospective study was to report the outcomes of two different methods in CC and AC reconstruction for the treatment of AC separation using a tendon graft and knot-hiding titanium clavicular implant. Twenty-seven patients with Rockwood grade III and V acromioclavicular (AC) separations were randomized into two groups. The primary outcome was whether taking the tendon graft through the coracoid risked a fracture. The following were secondary outcomes: follow-up of clavicular wound healing and Nottingham Clavicle score, Constant score, and Simple Shoulder Test results obtained preoperatively and 24months postoperatively. The anteroposterior radiographic change between the clavicular and coracoid cortexes and the clavicular tunnel diameter was measured postoperatively and 24months postoperatively. General patient satisfaction with the outcome (poor, fair, good, or excellent) was assessed 2years postoperatively. No coracoid fractures were detected. No issues in clavicular wound healing were detected. The mean Nottingham Clavicle score increased from a preoperative mean of 42.42 ± 13.42 to 95.31 ± 14.20 (P < 0.00). The Constant score increased from a preoperative mean of 50.81 ± 17.77 to 96.42 ± 11.51 (P < 0.001). The Simple Shoulder Test score increased from a preoperative mean of 7.50 ± 2.45 to 11.77 ± 1.18 (P < 0.001). The changes were significant. The coracoclavicular distance increased from 11.88 ± 4.00 to 14.19 ± 4.71 mm (P = 0.001), which was significant. The clavicular drill hole diameter increased from 5.5 to a mean of 8.00 ± 0.75 mm. General patient satisfaction was excellent. There were no significant differences between the two groups. There were no implant related complications in the clavicular wound healing. The results support the notion that good results are achieved by reconstructing both the CC and AC ligaments with a tendon graft. This clinical trial was registered on Clinicaltrials.gov.

Long-term clinical and radiographic outcomes of arthroscopic acromioclavicular stabilization for acute acromioclavicular joint dislocation.

Standard open acromioclavicular (AC) stabilization is associated with increased postoperative complications including deltoid injury, infection, tunnel complications, loss of reduction, and wound/cosmetic concerns. Arthroscopy may offer superior visualization and advantages that limit these risks. The aim of this prospective non-randomized study is to evaluate advantages and long-term reliability of arthroscopic AC stabilization. Thirty-two patients with acute grade III, IV and V AC dislocations underwent arthroscopic AC reconstruction with long-term assessment by clinical AC examination, Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, visual analog scale, Specific AC Score and Quick Disabilities of the Arm, Shoulder and Hand scores. Radiographs verified conservation of initial reduction and presence of coracoclavicular (CC) ossifications. Complications, revision rate, and satisfaction were assessed and compared to the literature. Mean follow-up time was 67.6 months. All clinical outcome scores improved and differences were statistically significant (P<0.001). Initial postoperative radiographs consistently showed complete reduction. Two patients experienced relapse to grade II AC dislocation without clinical implications. In total, 71.8% showed CC ossifications without functional impairment, and in 31.3% concomitant injuries were observed. Reintervention rate was 9.4%, and 96.9% of patients were satisfied with procedure outcomes. Arthroscopic stabilization for acute AC joint dislocations offers satisfactory clinical and radiographic outcomes, and our results show that the arthroscopic technique is reliable in the long run. We report better reduction in maintenance, fewer complications, and similar reoperation rates compared to other techniques. Level of evidence: III.

Tunnel-free acromioclavicular joint reconstruction is associated with improved initial reduction and higher patient satisfaction

Many surgical techniques have been described for acromioclavicular (AC) joint reconstruction. Creation of bone tunnels through the clavicle or coracoid has been shown to be a risk factor for fracture. Use of an AC reconstruction technique that does not create bone tunnels may obviate this risk. This study aims to evaluate clinical outcomes of AC joint reconstruction using a tunnel-free technique compared to reconstruction using a cortical button and clavicular drill holes. Consecutive patients who underwent AC joint reconstruction by a single surgeon in a subspecialty referral practice were included. One group of patients received cortical button fixation (button group), in which sutures were passed around the coracoid, brought up through a drill hole in the clavicle, and tied over a cortical button. The other group of patients received tunnel-free fixation, in which a self-locking tape suture was passed in a cerclage fashion around the base of the coracoid and the clavicle and tensioned with a tensioning device (cerclage group). Both groups underwent reconstruction of the coracoclavicular (CC) ligament and AC joint capsule using tibialis anterior allograft. Patient-reported outcome scores and satisfaction were collected and compared between groups. Radiographs were reviewed to evaluate CC ligament distance and loss of reduction. Twenty-two patients were included in the study (button n= 10, cerclage n= 12). Preoperative demographics and injury characteristics were not different between groups. Average radiographic follow-up was not different between groups (button: 231 days, cerclage: 105 days). Postoperative American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores were similar between groups. Two postoperative clavicle fractures were sustained in the button group. These occurred through clavicular drill holes and were preceded by tunnel widening. No fractures occurred in the cerclage group. CC distance at initial follow-up was significantly less in the cerclage group (button: 11.2 ± 4.5 mm, cerclage: 7.0 ± 2.9 mm, P=.023). Loss of reduction was similar throughout the postoperative period (button: 4.3 ± 2.6 mm, cerclage: 4.8 ± 4.1 mm, P >.05. Forty percent of patients were unsatisfied with their clavicle after button fixation (n= 4/10), compared with zero after cerclage fixation (n= 0/12, P=.03). Reasons for dissatisfaction were fracture (n= 2) and persistent cosmetic deformity (n= 2). Tunnel-free AC joint reconstruction is associated with improved initial radiographic appearance and patient satisfaction compared to single cortical button fixation. Postoperative clavicle fracture and persistent cosmetic deformity drive patient dissatisfaction, which may be minimized by avoiding clavicular drill holes and using a tensioned self-locking cerclage suture to improve initial reduction.

Deltotrapezial Stabilization of Acromioclavicular Joint Rotational Stability: A Biomechanical Evaluation.

Despite advances in surgical management of acromioclavicular (AC) joint reconstruction, many patients fail to maintain sustained anatomic reduction postoperatively. To determine the biomechanical support of the deltoid and trapezius on AC joint stability, focusing on the rotational stability provided by the muscles to posterior and anterior clavicular rotation. A novel technique was attempted to repair the deltoid and trapezius anatomically. Controlled laboratory study. Twelve human cadaveric shoulders (mean ± SD age, 60.25 ± 10.25 years) underwent servohydraulic testing. Shoulders were randomly assigned to undergo serial defects to either the deltoid or trapezius surrounding the AC joint capsule, followed by a combined deltotrapezial muscle defect. Deltotrapezial defects were repaired with an all-suture anchor using an anatomic technique. The torque (N·m) required to rotate the clavicle 20° anterior and 20° posterior was recorded for the following conditions: intact (native), deltoid defect, trapezius defect, combined deltotrapezial defect, and repair. When compared with the native condition, the deltoid defect decreased the torque required to rotate the clavicle 20° posteriorly by 7.1% (P = .206) and 20° anteriorly by 6.1% (P = .002); the trapezial defect decreased the amount of rotational torque posteriorly by 5.3% (P = .079) and anteriorly by 4.9% (P = .032); and the combined deltotrapezial defect decreased the amount of rotational torque posteriorly by 9.9% (P = .002) and anteriorly by 9.4% (P < .001). Anatomic deltotrapezial repair increased posterior rotational torque by 5.3% posteriorly as compared with the combined deltotrapezial defect (P = .001) but failed to increase anterior rotational torque (P > .999). The rotational torque of the repair was significantly lower than the native joint in the posterior (P = .017) and anterior (P < .001) directions. This study demonstrated that the deltoid and trapezius play a role in clavicular rotational stabilization. The proposed anatomic repair improved posterior rotational stability but did not improve anterior rotational stability as compared with the combined deltotrapezial defect; however, neither was restored to native stability. Traumatic or iatrogenic damage to the deltotrapezial fascia and the inability to restore anatomic deltotrapezial attachments to the acromioclavicular joint may contribute to rotational instability. Limiting damage and improving the repair of these muscles should be a consideration during AC reconstruction.

Anatomic Acromioclavicular Joint Reconstruction Using Semitendinosus Graft with Internal Bracing in Chronic Acromioclavicular Joint Dislocation: Case Series

Introduction: Acromioclavicular joint dislocations represent a frequent condition, affecting a very specific and generally active population and accounting for around 9% of all shoulder injuries. Case Presentation: We present a series of patients who underwent AC Joint reconstruction using Semitendinosus graft with internal bracing. The beach chair position is used for acromioclavicular reconstruction surgery. In this technique, we restore the anatomy, reconstruct the coracoclavicular ligament, and reinforced the acromioclavicular ligament. And it is reliable for chronic acromioclavicular joint injury. At final follow up we found excellent results with average pain score of 1.6, and average ROM of 160° of forward flexion and abduction, 70° of external rotation, and internal rotation level at T11. Postoperative function also showed great improvements with average ASES of 85 points, an average Constant Score of 89 points. This technique also achieved acceptable radiographic results, with an average coracoclavicular distance increase of 1.4 mm Discussion &amp; Conclusion: The loss of AC joint congruence with the Weaver Dunn procedure suggested that possibly the problem wasn’t only biological. This technique seems to be especially advantageous as it allows for an anatomic, biological, and minimally invasive procedure while avoiding some of the inconveniences described in other reports. Although demanding, it can be reproducibly performed arthroscopically, and good clinical outcomes should be expected.

Treatment of Failed Coracoclavicular Ligament Reconstructions: Primary Acromioclavicular Ligament and Capsular Reconstruction and Revision Coracoclavicular Ligament Reconstruction

Acromioclavicular (AC) joint dislocations are a common injury affecting 2 of every 10,000 people in the general population and comprise 9% to 12% of all injuries to the shoulder. Most injuries occur through contact activity, which drives the acromion inferiorly with the clavicle remaining in its anatomic position, initiating a cascade of injury propagating from the AC ligament followed by failure of the coracoclavicular ligaments. Many techniques have been described for AC joint injuries, without a consensus gold standard. The revision setting offers even less consensus on treatment options and countless difficulties for surgeons. There have been more than 60 described procedures regarding AC and coracoclavicular ligament reconstructions, with significant controversy regarding the optimal intervention for each injury. When these techniques fail, it is important to pinpoint the mechanism of failure to construct a successful plan for revision. The purpose of this Technical Note is to describe our preferred method of primary AC and revision coracoclavicular reconstruction using a combination of autograft and allograft semitendinosus as well as TightRope fixation.

Kinematic and Radiographic Evaluation of Acromioclavicular Reconstruction with a Synthetic Ligament.

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

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

Optimal treatment of chronic unstable acromioclavicular (AC) joint dislocations (stage 3-5 according the Rockwood classification) is still debated. Anatomic coracoclavicular (CC) reconstruction is a reliable option in terms of two-dimensional radiographic reduction, clinical outcomes, and return to sports, but there remain concerns regarding anterior-posterior stability of the AC joint with CC ligament reconstruction alone. The aim of the present study was to describe the mid-term results of a new hybrid technique with CC and AC ligament reconstruction for chronic AC joint dislocations. Twenty-two patients surgically treated for chronic AC joint dislocations (grade 3 to 5) were retrospectively reviewed. All patients were assessed before surgery and at final follow-up with the Constant-Murley score (CMS) and the American Shoulder and Elbow Surgeons (ASES) score. The CC vertical distance (CCD) and the CCD ratio (affected side compared to unaffected side) were measured on Zanca radiographs preoperatively, at 6months postop and at final follow-up. The same surgical technique consisting in a primary fixation with a suspensory system, coracoclavicular ligaments reconstruction with a double loop of autologous gracilis and acromioclavicular ligaments reconstruction with autologous coracoacromial ligament was performed in all cases. Twenty-two shoulders in 22 patients (19 males and 3 females) were evaluated with a mean age of 34.4 ± 9years at the time of surgery. The mean interval between the injury and surgery was 53.4 ± 36.7days. The mean duration of postoperative follow-up was 49.9 ± 11.8months. According to the Rockwood classification, there were 5 (22.6%) type-III and 17 (77.2%) type-V dislocations. Mean preoperative ASES and CMS were 54.4 ± 7.6 and 64.6 ± 7.2, respectively. They improved to 91.8 ± 2.3 (p = 0.0001) and 95.2 ± 3.1 (p = 0.0001), respectively at final FU. The mean preoperative CCD was 22.4 ± 3.2mm while the mean CCD ratio was 2.1 ± 0.1. At final FU, the mean CCD was 11.9 ± 1.4mm (p = 0.002) and the mean CCD ratio was 1.1 ± 0.1 (p = 0.009). No recurrence of instability was observed. One patient developed a local infection and four patients referred some shoulder discomfort. Heterotopic ossifications were observed in three patients. The optimal treatment of chronic high-grade AC joint dislocations requires superior-inferior and anterior-posterior stability to ensure good clinical outcomes and return to overhead activities or sports. The present hybrid technique of AC and CC ligaments reconstruction showed good clinical and radiographic results and is a reliable an alternative to other reported techniques. Level IV.

Acromioclavicular Joint Reconstruction with Recessed Clavicular Implant Technique Guide

Acromioclavicular (AC) joint injuries are common and often require operative intervention. Although there are many described surgical techniques, there remains a lack of consensus on the optimal technique. The purpose of this Technical Note is to provide our preferred method of AC reconstruction with a recessed clavicular implant and semitendinosus allograft, which mitigates hardware pain associated with arthroscopic techniques.

Arthroscopic Coracoclavicular Reconstruction Combined with Open Acromioclavicular Reconstruction Using Knot Hiding Clavicular Implants Is a Stable Solution

PurposeThe purpose of this noninterventional, register-based study was to report the outcomes and wound healing of surgically treated chronic acromioclavicular (AC) dislocations using a tendon graft and knot-hiding titanium implants.MethodsThirty-two cases with chronic AC separation underwent an arthroscopic coracoclavicular (CC) ligament reconstruction and an open AC ligament reconstruction using knot-hiding titanium implants. The wound healing was assessed 2 months after the operation. The Nottingham Clavicle score, Constant score, and Simple Shoulder Test were obtained postoperatively and at a minimum of one-year postsurgery. The radiographic change in distance between the clavicular and coracoid cortices and clavicular tunnel diameter was measured. General patient satisfaction with the outcome (poor, fair, good, or excellent) was also assessed 1 year postoperatively.ResultsThe mean Nottingham Clavicle score increased from a preoperative mean of 41.66 ± 9.86 to 96.831 ± 5.86 (P ≤ .05). The Constant score increased from a preoperative mean of 44.66 ± 12.54 to 93.59 ± 7.01 (P ≤ .05). The Simple Shoulder Test score increased from a preoperative mean of 7.00 ± 2.14 to 11.84 ± .63 (P ≤ .05). The coracoclavicular distance increased from 11.32 ± 3.71 to 13.48 ± 3.79 mm (P ≤ .05). The clavicular drill hole diameter increased from 6 mm to a mean of 6 to a mean of 8.13 ± 1.12 mm. Twenty-three (71.9%) patients reported an excellent outcome, and nine (28.1%) reported a good outcome. One clavicular fracture occurred but no coracoid fractures. There was one reconstruction failure leading to a reoperation.ConclusionsIn this series, combining the arthroscopic CC ligament reconstruction to an open reconstruction of the AC joint with a tendon graft proved to be a stable solution. The knot-hiding titanium implant effectively eliminated the problems related to the clavicular wound healing.Level of EvidenceLevel IV, therapeutic case series.

Better Radiographic Reduction and Lower Complication Rates With Combined Coracoclavicular and Acromioclavicular Ligament Reconstruction Than With Isolated Coracoclavicular Reconstruction

PurposeTo determine whether combined acromioclavicular (AC) ligament reconstruction and coracoclavicular (CC) ligament reconstruction without bone tunnels would improve radiographic reduction maintenance and complication rates for type III to V AC dislocations.MethodsThis single-institution retrospective study analyzed all patients who underwent a hybrid synthetic/graft wrap CC reconstruction without tunnels with additional AC reconstruction/repair from January 2013 to August 2019. This 26-patient cohort was compared with a 1:1 sex- and age-matched control group who underwent CC reconstruction without AC reconstruction. CC distances on postoperative radiographs were compared with normal contralateral shoulders.ResultsOf the 93 patients who underwent AC reconstructive surgery during this time period, 26 patients (96% male) met the inclusion criteria. The AC/CC cohort had 23.5% type III injuries, 23.1% type IV injuries, and 53.8% type V injuries, similar to the control group. Final radiographs of the operative shoulder’s CC distance were (mean ± standard deviation) 0.9 ± 4.0 mm greater than that of the contralateral shoulder (9.6 ± 8.7 mm) in the AC/CC cohort. Final radiographs of the operative shoulder’s coracoclavicular distance were 4.0 ± 4.7 mm greater than that of the contralateral shoulder (13.3 ± 9.3 mm) in the CC control group, a significant difference (P = .014). The AC/CC reconstruction group had fewer patients with a loss of reduction >5 mm (11.5% versus 38.5%, P = .025). The complication rate in the CC control group was higher than in the AC/CC cohort (30.7% versus 7.7%, P = .035). The reoperation rate was also greater in the CC control group (8 versus 1, P = .010).ConclusionThis cohort study shows that the addition of AC reconstruction to CC reconstruction using synthetic tapes/grafts or allograft tissues without bone tunnels significantly improves durable radiographic outcomes, diminishes complication rates, and improves reoperation rates.Level of EvidenceIII, retrospective comparative study.

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

The aim of the present biomechanical study was to evaluate the stability of a novel simple and cost-effective mini-open double cow-hitch suture button technique of acromioclavicular (AC) joint stabilization in comparison to a well-established double tight-rope technique. A total of 12 fresh-frozen cadaveric shoulders were randomized into two treatment groups. In either a coracoclavicular stabilization with a standard double tight-rope technique (Group 1; n = 6, age 78years ± 10) or a double cow-hitch with two No. 5 FiberWire strains looped in a bicortical button placed at the bottom of the coracoid process (Group 2; n = 6, age 80years ± 13). Both techniques were equally augmented with an AC joint cerclage using a FiberTape. All shoulders were tested in a servo-hydraulic material testing machine for elongation/cyclic displacement (in mm) after cyclic loading (70N cyclical load, 1500 cycles), stiffness (N/mm) and ultimate load to failure (N). The mechanism of failure was recorded. All tests were performed in a previously published testing setup. After 1500 cycles, group 2 showed a cyclic displacement of 1.67mm (SD 0.85), compared to 1.04mm (SD 0.23) cyclic displacement in group 1 (p = 0.11). The cyclic displacement after AC reconstruction in group 1 was 0.36mm lower than in the native state with intact ligaments (p = 0.19), whereas the cyclic elongation in group 2 was 0.05mm higher compared to the native situation (p = 0.87). Stiffness after reconstruction was significantly higher in group 1 compared to the native specimen (p = 0.001), in group 2 it was similar as before the reconstruction (p = 0.64). Ultimate load to failure and stiffness were higher in group 1 with 424N (SD 237) and 68.6N/mm (SD 8.2), compared to 377N (SD 152) and 68N/mm (SD 13.3) in group 2, without reaching statistical significance (p = 0.69 and 0.89). The most common failure modes were clavicular fractures at the tight rope drill holes (n = 2) and clavicular fractures medially at the fixation site (n = 2) in group 1, and coracoid button break-through (n = 3) and clavicular fractures medially at the fixation site (n = 2) in group 2. Stabilization of the AC joint with a novel mini-open double cow-hitch suture button technique resulted in a similar low elongation, high stiffness and ultimate load to failure compared to a double tight-rope technique. This cost-effective technique for AC joint stabilization could demonstrate a sufficient biomechanical stability with especially high stiffness and load-to-failure. Biomechanical study.

Severe and Rapid Post-Traumatic Osteolysis of the Distal Clavicle in a College Athlete: A Case Report and Review of the Literature

Case Report: A 21-year-old female college athlete presented with continually worsening distal clavicle osteolysis. After conservative management and significant activity modification failed to resolve pain, surgical management was considered. Instability in the sagittal plane was believed to contribute to her persistent pain. Surgical management included acromioclavicular (AC) ligament reconstruction, in addition to the standard distal clavicle excision. Conclusion: Horizontal instability in the AC joint may contribute to the failure of conservative treatment in patients with distal clavicle osteolysis. If surgical management is considered, AC ligament reconstruction, in addition to the standard distal clavicle excision, may provide additional benefit in functional outcomes.

Anatomic reconstruction of acromioclavicular joint dislocations using allograft and synthetic ligament

BackgroundAcromioclavicular (AC) separations are commonly seen shoulder injuries. Numerous surgical reconstruction techniques have been described. In this study, we present a series of patients who underwent an anatomic reconstruction using a synthetic ligament and allograft construct.MethodsWe performed a retrospective review of patients with type IV or V AC separations who underwent primary or revision AC reconstruction with a luggage-tag synthetic ligament and a semitendinosus allograft placed through the anatomic insertion sites of the coracoclavicular ligaments. Patient-reported outcomes, as well as complication rates, were recorded at a minimum 2-year follow-up.ResultsTen patients with a mean age of 44.2 ± 14.9 years were included in the study. The mean Disabilities of the Arm, Shoulder and Hand score was 15.5 ± 15.4; mean Single Assessment Numeric Evaluation score, 81.8 ± 12.1; mean Simple Shoulder Test score, 11.4 ± 1.1; mean American Shoulder and Elbow Surgeons score, 84.6 ± 15.7; mean Constant score, 82.5 ± 11.6; and mean visual analog scale score, 2 ± 2.6.ConclusionThe technique using a luggage-tag synthetic ligament along with an anatomic allograft coracoclavicular ligament reconstruction is a safe, effective alternative to other techniques described in the literature.

Horizontal Instability of the Acromioclavicular Joint: A Systematic Review

Background: Injuries to the acromioclavicular (AC) joint are common and should be suspected in patients who have shoulder pain in the region of the acromion and clavicle. Injuries to the AC ligament can cause horizontal instability and are often neglected or underdiagnosed, which can lead to poor patient outcomes. Purpose: To perform a systematic review of the literature on the diagnosis and treatment of horizontal instability of the AC joint. Study Design: Systematic review. Methods: The authors performed a systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies that investigated diagnosis, treatment, and failure of operative management of acute and chronic AC separations. Studies that did not specifically evaluate AC joint injuries, were not written in English, or were specific only to vertical instability of the AC joint were excluded. Results: Overall, 23 articles met the inclusion criteria and were therefore included in this systematic review. Diagnosing horizontal AC instability is difficult using plain radiographs; dynamic views were shown in some cases to better detect horizontal instability than with static views. More than 60 procedures for treating AC joint injuries have been published, but many focus on vertical rather than horizontal instability. Modifications to current surgical procedures to incorporate reconstruction of the horizontal component showed improved patient outcomes. Such modifications included additional AC joint suture cord cerclage, combined AC and coracoclavicular ligament reconstruction, and the Twin Tail TightRope triple button technique. Failure after surgical stabilization of AC joint separation has been reported to occur in 15% to 80% of cases. Conclusion: No consensus is available regarding the best practices for diagnosis, evaluation, and treatment of acute or chronic horizontal instability of the AC joint. Moreover, horizontal instability injuries are often neglected or poorly understood, making diagnosis difficult, which may lead to high complication rates and failure after surgical stabilization.

Primary Acromioclavicular-Coracoclavicular Reconstruction Using 2 Allografts, TightRope, and Stabilization to the Acromion

Acromioclavicular (AC) joint injuries are a common cause of shoulder pain, particularly among young athletes participating in contact sports. Injuries to the AC joint most commonly occur from direct impact at the acromion and are classified as types I to VI. Although most AC joint injuries can be treated nonoperatively, types IV to VI are best treated with surgery, with type III being controversial and most surgeons recommending an initial trial of nonoperative treatment. Although numerous surgical techniques have been described, no gold standard technique has been established. Biomechanical testing suggests that anatomic reconstruction of both the AC and coracoclavicular ligaments results in a superior surgical construct. The objective of this Technical Note is to describe our preferred technique for the primary treatment of AC joint instability in the acute and chronic setting. Using 2 free tendon grafts in combination with a cortical button suspensory device combines the advantages of a nonrigid biologic and anatomic AC and coracoclavicular ligament reconstruction while benefiting from the strength of a cortical suspensory device in resisting displacement of the AC joint.

Motion Tracking for Quantitative and Qualitative Assessment of Upper Limb Movements Following Acromioclavicular Joint Ligament Reconstruction: A Pilot Study

Background: Technological tools as robotic devices and wearable sensors can provide accurate and repeatable measurements of physical variables (e.g., position, velocities, forces) which can be used for quantitative and qualitative assessment of movement analysis and upper limb motor performance. Objective: The study aims to propose a quantitative and qualitative assessment of upper limb motor performance by means of seven kinematic parameters recorded by a passive mechatronic device in patients who underwent a surgical procedure for ligament reconstruction following acromioclavicular joint dislocation. Method: Five patients (mean age: 40 ± 12 years) with acromioclavicular joint dislocation were enrolled. A passive end-effector mechatronic device characterized by 7 degrees of freedom and designed for the assessment of upper limb motor performance - especially for measuring the hand position in three-dimensional space - was used. The Constant-Murley score and seven kinematic parameters were used as clinical outcome measure and quantitative and qualitative assessment, respectively. Results: The preliminary results of this study show no significant differences between the impaired arm and unimpaired arm: the end-effector passive mechatronic device used in this study is able to provide an overall assessment of the upper limb motor performance following shoulder impairment. Conclusion: The motion tracker can be easily used as effective tool for quantitative and qualitative assessment of upper limb motor performance, even several years after the surgical operation.

Functional and Radiographic Outcomes After Allograft Anatomic Coracoclavicular Ligament Reconstruction.

To analyze the functional and radiographic outcomes of anatomic coracoclavicular ligament reconstruction (ACCR) using allograft tendon without interference screw fixation. Retrospective nonrandomized study. Level I trauma center (University Hospital). Seventeen patients (mean age of 44 years) with Rockwood III through V acromioclavicular joint disruptions. Twelve of 17 patients had a primary reconstruction, including 4 patients sustaining their injuries as part of a polytrauma incident. Five of 17 patients were revisions of a previously failed acromioclavicular reconstruction procedure. Open ACCR using hamstring allograft with high-strength suture augmentation and knotted graft fixation without interference screws. Clinical and patient reported outcome measures including Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and visual analog scale scores for pain and radiographic outcomes. The average final postoperative Simple Shoulder Test and American Shoulder and Elbow Surgeons scores were 10.8 and 80.5, respectively. The average final postoperative visual analog scale pain was 1.8. All patients demonstrated clavicle tunnel widening on final postoperative radiographs compared with immediate postoperative radiographs. The overall complication rate was 36%, with no clavicle or coracoid fractures. Open ACCR using hamstring allograft tendon secured with a square knot and high-strength suture augmentation yields equivalent outcomes to those repairs requiring an additional interference screw. Clavicle tunnel widening predictably occurs, but the clinical significance is undetermined. It appears therefore that an interference screw is not needed. Larger comparison studies are needed. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcomes of a single-tunnel technique for coracoclavicular and acromioclavicular ligament reconstruction

A large number of surgical techniques have been described to treat acromioclavicular (AC) joint separations. Despite the high success rates with double-tunnel reconstruction, this method has been associated with the risk of coracoid and clavicle fractures. This study aimed to evaluate the outcomes of the first cohort of patients who underwent single-tunnel AC and coracoclavicular (CC) ligament reconstruction. It was hypothesized that this technique would result in maintenance of reduction and a minimal risk of fracture of the coracoid and clavicle. All patients who underwent single-tunnel AC joint reconstruction between 2012 and 2015 via the technique with 2-year follow-up were included. Objective outcomes recorded were maintenance of reduction as measured by the CC distance on radiographs, shoulder range of motion, strength, return to sports, and complications. Subjective outcomes included maintenance of reduction on visual inspection and various patient-reported outcomes. Seventeen patients were included with a mean age of 41 ± 12 years. Separation types included types III, IV, and V. The mean follow-up period was 29 ± 9 months (range, 16-45 months). The CC distance improved from 37.4 to 30.0 mm on plain radiographs (P = .006), the American Shoulder and Elbow Surgeons score improved from 67.0 to 90.1 (P = .094), and the Single Assessment Numeric Evaluation score improved from 30.5 to 91.1 (P = .025). Reduction on visual inspection was maintained in 16 patients (94.1%). Regarding sports participation, 14 patients (82.4%) returned to their preinjury level. The most common complication was a prominent suture knot stack, occurring in 3 patients (17.6%), which was removed in all 3 in a second procedure. There were no clavicle or coracoid fractures. The described technique results in satisfactory objective and patient-reported outcomes and return to sports while avoiding coracoid and clavicle fractures.