Surgical Treatment of Chronic Acromionclavicular Dislocation with Biologic Graft vs. Artificial Ligament at Long Term Follow-Up (original) (raw)
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The Cochrane library, 2019
BackgroundDislocation of the acromioclavicular joint is one of the most common shoulder injuries in a sport‐active population. The question of whether surgery should be used remains controversial. This is an update of a Cochrane Review first published in 2010.ObjectivesTo assess the effects (benefits and harms) of surgical versus conservative (non‐surgical) interventions for treating acromioclavicular dislocations in adults.Search methodsWe searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to June 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 6), MEDLINE (1946 to June 2019), Embase (1980 to June 2019), and LILACS (1982 to June 2019), trial registries, and reference lists of articles. There were no restrictions based on language or publication status.Selection criteriaWe included all randomised and quasi‐randomised trials that compared surgical with conservative treatment of acromioclavicular dislocation in adults.Data collection and analysisAt least two review authors independently performed study screening and selection, 'Risk of bias' assessment, and data extraction. We pooled data where appropriate and used GRADE to assess the quality of evidence for each outcome.Main resultsWe included five randomised trials and one quasi‐randomised trial. The included trials involved 357 mainly young adults, the majority of whom were male, with acute acromioclavicular dislocation. The strength of the findings in all studies was limited due to design features, invariably lack of blinding, that carry a high risk of bias. Fixation of the acromioclavicular joint using hook plates, tunnelled suspension devices, coracoclavicular screws, acromioclavicular pins, or (usually threaded) wires was compared with supporting the arm in a sling or similar device. After surgery, the arm was also supported in a sling or similar device in all trials. Where described in the trials, both groups had exercise‐based rehabilitation. We downgraded the evidence for all outcomes at least two levels, invariably for serious risk of bias and serious imprecision.Low‐quality evidence from two studies showed no evidence of a difference between groups in shoulder function at one year, assessed using the Disability of the Arm, Shoulder, and Hand questionnaire (DASH) (0 (best function) to 100 (worst function)): mean difference (MD) 0.73 points, 95% confidence interval (CI) −2.70 to 4.16; 112 participants. These results were consistent with other measures of function at one‐year or longer follow‐up, including non‐validated outcome scores reported by three studies. There is low‐quality evidence that function at six weeks may be better after conservative treatment, indicating an earlier recovery. Very low‐quality evidence from one trial found no difference between groups in participants reporting pain at one year: risk ratio (RR) 1.32, 95% CI 0.54 to 3.19; 79 participants. There is very low‐quality evidence that surgery may not reduce the risk of treatment failure, usually resulting in non‐routine secondary surgery: 14/168 versus 15/174; RR 0.99, 95% CI 0.51 to 1.94; 342 participants, 6 studies. The main source of treatment failure was complications related to surgical implants in the surgery group and persistent symptoms, mainly discomfort, due to the acromioclavicular dislocation in the conservatively treated group.There is low‐quality evidence from two studies that there may be little or no difference between groups in the return to former activities (sports or work) at one year: 57/67 versus 62/70; RR 0.96, 95% CI 0.85 to 1.10; 137 participants, 2 studies. Low‐quality but consistent evidence from four studies indicated an earlier recovery in conservatively treated participants compared with those treated with surgery. There is low‐quality evidence of no clinically important difference between groups at one year in quality of life scores, measured using the 36‐item or 12‐item Short Form Health Survey (SF‐36 or SF‐12) (0‐to‐100 scale, where 100 is best score), in either the physical component (MD −0.63, 95% CI −2.63 to 1.37; 122 participants, 2 studies) or mental component (MD 0.47 points, 95% CI −1.51 to 2.44; 122 participants). There is very low‐quality and clinically heterogenous evidence of a greater risk of an adverse event after surgery: 45/168 versus 16/174; RR 2.82, 95% CI 1.65 to 4.82; 342 participants, 6 studies; I2 = 48%. Common adverse outcomes were hardware complications or discomfort (18.5%) and infection (8.7%) in the surgery group and persistent symptoms (7.1%), mainly discomfort, in the conservatively treated group. The majority of surgical complications occurred in older studies testing now‐outdated devices known for their high risk of complications. The very low‐quality evidence from one study (70 participants) means that we are uncertain whether there is a between‐group difference in patient dissatisfaction with cosmetic results.It is notable that the evidence for function, return to former activities, and quality of life came from the two most recently conducted studies, which tested currently used devices and interventions in clearly defined participant populations that represented the commonly perceived population for which there is uncertainty over the use of surgery. There were insufficient data to conduct subgroup analysis relating to type of injury and whether surgery involved ligament reconstruction or not.Authors' conclusionsThere is low‐quality evidence that surgical treatment has no additional benefits in terms of function, return to former activities, and quality of life at one year compared with conservative treatment. There is, however, low‐quality evidence that people treated conservatively had improved function at six weeks compared with surgical management. There is very low‐quality evidence of little difference between the two treatments in pain at one year, treatment failure usually resulting in secondary surgery, or patient satisfaction with cosmetic result. Although surgery may result in more people sustaining adverse events, this varied between the trials, being more common in techniques such as K‐wire fixation that are rarely used today. There remains a need to consider the balance of risks between the individual outcomes: for example, surgical adverse events, including wound infection or dehiscence and hardware complication, against risk of adverse events that may be more commonly associated with conservative treatment such as persistent symptoms or discomfort, or both.There is a need for sufficiently powered, good‐quality, well‐reported randomised trials of currently used surgical interventions versus conservative treatment for well‐defined injuries.
Current Concepts in the Treatment of Acromioclavicular Joint Dislocations
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2013
Purpose: To conduct a systematic review of the literature in relation to 3 considerations in determining treatment options for patients with acromioclavicular (AC) joint dislocations: (1) operative versus nonoperative management, (2) early versus delayed surgical intervention, and (3) anatomic versus nonanatomic techniques. Methods: The PubMed database was searched in October 2011 using the single term acromioclavicular and the following search limits: any date, humans, English, and all adult (19þ). Studies were included if they compared operative with nonoperative treatment, early with delayed surgical intervention, or anatomic with nonanatomic surgical techniques. Exclusion criteria consisted of the following: Level V evidence, laboratory studies, radiographic studies, biomechanical studies, fractures or revisions, meta-analyses, and studies reporting preliminary results. Results: This query resulted in 821 citations. Of these, 617 were excluded based on the title of the study. The abstracts and articles were reviewed, which resulted in the final group of 20 studies that consisted of 14 comparing operative with nonoperative treatment, 4 comparing early with delayed surgical intervention, and 2 comparing anatomic with nonanatomic surgical techniques. The lack of higher level evidence prompted review of previously excluded studies in an effort to explore patterns of publication related to operative treatment of the AC joint. This review identified 120 studies describing 162 techniques for operative reconstruction of the AC joint. Conclusions: There is a lack of evidence to support treatment options for patients with AC joint dislocations. Although there is a general consensus for nonoperative treatment of Rockwood type I and II lesions, initial nonsurgical treatment of type III lesions, and operative intervention for Rockwood type IV to VI lesions, further research is needed to determine if differences exist regarding early versus delayed surgical intervention and anatomic versus nonanatomic surgical techniques in the treatment of patients with AC joint dislocations.
International journal of shoulder …, 2008
Acromioclavicular joint dislocations are common injuries, which typically occur with trauma in young men. Treatment recommendations for these injuries are highly variable and controversial. There are greater than 100 surgical techniques described for operative treatment of this injury. One of the most widely recommended methods of surgical reconstruction for acromioclavicular joint dislocations is to utilize the coracoacromial ligament for stabilization of the distal clavicle. Several modifications of this procedure have been described which have involved adjunct coracoclavicular fixation or fixation across acromioclavicular joint. Although the literature is replete with descriptive papers, there is paucity of studies evaluating the surgical outcome of this procedure. We systematically reviewed the English language published literature in peer reviewed journals (Medline, EMBASE, SCOPUS) and assigned a level of evidence for available studies. We critically reviewed each paper for the flaws and biases and then evaluated the comparable clinical outcomes for various procedures and their modifications. The published literature consists entirely of case series (Level IV evidence) with variability in surgical technique and outcome measures. On review there is low level evidence to support the use of coracoacromial ligament for acromioclavicular dislocation but it has been associated with high rate of deformity recurrence. Adjunct fixation does not improve clinical results when compared to isolated coracoacromial ligament transfer. This is in part because of the high incidence of fixation related complications. Similar results are reported with coracoacromial ligament reconstruction for acute and chronic cases. The development of secondary acromioclavicular joint symptoms with distal clavicle retention is poorly reported with the incidence rate varying from 12% to 32%. Despite this, the retention or excision of distal clavicle did not affect overall clinical results except in the patients with pre existing acromioclavicular joint osteoarthritis who have inferior results with retention of distal end of clavicle. Further well designed clinical trials with validated outcome measures are required to fully evaluate the clinical results of this procedure.
Knee Surgery, Sports Traumatology, Arthroscopy, 2021
Purpose Optimal treatment of chronic unstable acromioclavicular (AC) joint dislocations (stage 3-5 according the Rockwood classification) is still debated. Anatomic coracoclavicular (CC) reconstruction is a reliable option in terms of two-dimensional radiographic reduction, clinical outcomes, and return to sports, but there remain concerns regarding anterior-posterior stability of the AC joint with CC ligament reconstruction alone. The aim of the present study was to describe the mid-term results of a new hybrid technique with CC and AC ligament reconstruction for chronic AC joint dislocations. Methods Twenty-two patients surgically treated for chronic AC joint dislocations (grade 3 to 5) were retrospectively reviewed. All patients were assessed before surgery and at final follow-up with the Constant-Murley score (CMS) and the American Shoulder and Elbow Surgeons (ASES) score. The CC vertical distance (CCD) and the CCD ratio (affected side compared to unaffected side) were measured on Zanca radiographs preoperatively, at 6 months postop and at final followup. The same surgical technique consisting in a primary fixation with a suspensory system, coracoclavicular ligaments reconstruction with a double loop of autologous gracilis and acromioclavicular ligaments reconstruction with autologous coracoacromial ligament was performed in all cases. Results Twenty-two shoulders in 22 patients (19 males and 3 females) were evaluated with a mean age of 34.4 ± 9 years at the time of surgery. The mean interval between the injury and surgery was 53.4 ± 36.7 days. The mean duration of postoperative follow-up was 49.9 ± 11.8 months. According to the Rockwood classification, there were 5 (22.6%) type-III and 17 (77.2%) type-V dislocations. Mean preoperative ASES and CMS were 54.4 ± 7.6 and 64.6 ± 7.2, respectively. They improved to 91.8 ± 2.3 (p = 0.0001) and 95.2 ± 3.1 (p = 0.0001), respectively at final FU. The mean preoperative CCD was 22.4 ± 3.2 mm while the mean CCD ratio was 2.1 ± 0.1. At final FU, the mean CCD was 11.9 ± 1.4 mm (p = 0.002) and the mean CCD ratio was 1.1 ± 0.1 (p = 0.009). No recurrence of instability was observed. One patient developed a local infection and four patients referred some shoulder discomfort. Heterotopic ossifications were observed in three patients. Conclusions The optimal treatment of chronic high-grade AC joint dislocations requires superior-inferior and anterior-posterior stability to ensure good clinical outcomes and return to overhead activities or sports. The present hybrid technique of AC and CC ligaments reconstruction showed good clinical and radiographic results and is a reliable an alternative to other reported techniques. Level of evidence Level IV.
Modern Attitude in the Treatment of Acromio-Clavicular Displacement
2017
The acromioclavicular joint dislocation represents a common shoulder injury that frequently occurs to young and active individuals. Most of these AC lesions can be treated conservatively but high-grade dislocation need surgical treatment. There are numerous surgical techniques described in literature for treating this injury. The surgeons must choose between open reduction with internal fixation and arthroscopic fixation, which is the latest technique developed. The aim of this study is to evaluate the functional results and the level of pain after an arthroscopic fixation using a TightRope system to treat AC dislocation. It is a less invasive technique, allowing a stable fixation of the joint. In our study we analyzed 48 patients with acute acromioclavicular dislocation, all of them surgically treated using an arthroscopic method with a single TightRope device. An important reduction in pain perception was achieved at six months after the surgery, comparing with the preoperative mo...
ARC Journal of Orthopedics, 2020
Background: Acromioclavicular (AC) joint separation/dislocation represents widely recognized as shoulder injuries seen in general orthopedic. The recent biomechanical study of the AC joint made a lot of changes in the Treatment modalities of the joint. Objective: our aim is to report the clinical outcome of management of acute acromioclavicular (AC) joint dislocation type III and V by clavicular hook plate with direct coracoclavicular ligament repair. Patients and Method: A prospective study including thirty Four patients with AC joint dislocation type III and V Rockwood classification was conducted from June 2014 to October 2018 in our University Hospitals. Patients were treated by open reduction of the dislocated AC joint and internal fixation by clavicular hook plate together with direct repair of the coracoclavicular (CC) ligament. Three patients lost during follow up and operation one patient died during follow up from cardiac problem before the surgery. The patients were evaluated by plain radiography for AC joint stability and functionally by Constant-Murley Score. Results: Thirty patients with 22 patients (73.3%) were male and eight patients (24.7%) were female. The mean follow-up period was 24±4.3 months (range 18-32 months). The mean age was 30±4.5 years (range 20-43 years). The operative time of our procedure was of a mean of 42±2.4 minutes (range 34-59). All the patients had the plate removed after the third month postoperatively the mean 102±3.4 days (range 89-125). Follow-up radiograph after plate removal showed maintained reduction of AC joint in 28 patients. In the other two patients, loss of reduction of 1-2mm was noticed. The mean Constant-Murley score in the last follow-up was 93±5.6 (range 85-99). Conclusion: A good functional outcome and low complication rate was reported with the used our approach in comparison with other operative procedures.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2014
Purpose: To evaluate the incidence of associated pathologic shoulder lesions that were addressed surgically in grade 3 acromioclavicular joint (ACJ) dislocations, as well as to compare this incidence between younger and older patients and between acute and chronic cases. Methods: In this multicenter nonrandomized retrospective study, 98 patients operated on for grade 3 ACJ dislocation underwent concomitant arthroscopic evaluation for the identification and treatment of any associated lesions. The type and treatment of associated lesions were collected in a central database and analyzed. We classified patients according to age (<45 years and 45 years) and according to the length of time between trauma and surgical treatment (30 days and 120 days), obtaining the following stratification: younger acute, older acute, younger chronic, and older chronic. Results: Of the patients, 42 (42.8%) were diagnosed with at least 1 additional pathologic lesion, and 29 (29.5%) required a dedicated additional treatment. Rates of treatment on associated lesions were analyzed: younger versus older groups presented a significant difference, as did younger acute versus older acute groups; SLAP and posterior rotator cuff tear treatments represented 24 of the 35 additional surgeries (68.5%). Conclusions: The overall rate of associated pathologic lesions requiring additional surgical treatment in patients with ACJ dislocation was 29.5%. Patients aged 45 years or older had a greater risk of presenting with associated lesions that needed to be surgically addressed (odds ratio, 3.01). The overall rates of associated surgical lesions in acute versus chronic cases were not shown to be significantly different. Level of Evidence: Level IV, prognostic case series.