Treatment of Acute Acromioclavicular Joint Dislocations Type III and Type V by Rockwood Classification Using a Dynamic Stabilization System under Arthroscopic Control with and without Suture of the Ligaments of the Acromioclavicular Joint

Summary. Acute acromioclavicular (AC) joint dislocation is still a challenging task for orthopedic surgeons. Objective: to compare the clinical and radiological results of treatment of patients with acute dislocation of the acromial end of the clavicle who were treated with a dynamic stabilization system with and without suture of acromioclavicular ligaments under arthroscopic control. Materials and Methods. A retrospective analysis of the treatment of 44 patients with acute AC joint dislocations type III and type V by Rockwood classification was performed. The patients were divided into 2 groups: group I – 18 patients (40.9%) who underwent stabilization of the dislocation and fixation of the acromial end of the clavicle using a dynamic stabilization system and suture of the ligaments of the acromioclavicular joint under arthroscopic control; group II – 26 patients (59.1%) who underwent stabilization of the dislocation and fixation of the acromial end of the clavicle using a dynamic stabilization system without suture of the ligaments of the acromioclavicular joint under arthroscopic control. There were 40 male (90.9%) and 4 female (9.1%) patients aged 18–58 years (mean age 32.9±10.1 years). The mean time from injury to surgical treatment was 8.3±3.2 days (from 3 to 17 days). Clinical observation was carried out at an average time of 20.1±3.9 months after surgery (from 12 to 28 months). Clinical outcomes were assessed using the Oxford Shoulder scale, the Constant-Murley scale, and the Acromioclavicular Joint Instability Scoring System. Results. The mean Oxford Shoulder score at the final follow-up on the injured side was 45.8±1.3 points and 46.2±1.3 points (p=0.422) in groups I and II, respectively. The mean Constant-Murley score at the final follow-up on the injured side was 94.6±2.4 points and 91.7±4.2 points (p=0.0134) in groups I and II, respectively. The mean score on the Acromioclavicular Joint Instability Scoring System at the final follow-up on the injured side was 83.8±7.1 points and 78.1±11.8 points (p=0.075) in groups I and II, respectively. No significant complications were observed in both groups. Conclusions. The combination of the arthroscopically assisted technique of reconstruction of the acromioclavicular ligaments using high-strength sutures and fixation of the coracoclavicular ligaments using a dynamic stabilization system provides good long-term clinical results.

Acromioclavicular Reconstruction Using Semitendinosus Tendon Autograft: A Technical Note and Case Report

Background: Although there are several surgical options for the treatment of acromioclavicular joint (ACJ) dislocation, there is no definite gold standard. Anatomical reconstruction techniques are becoming more popular due to the new understandings of the anatomy and biomechanics of the ACJ. Case Report: A 40-year-old male with left ACJ dislocation (Type 3 Rockwood classification) underwent anatomical reconstruction with a semitendinosus tendon graft harvested from the left knee. Conclusion: Anatomical reconstruction of ACJ by autograft is an effective treatment option.

The Role of the Acromioclavicular Ligament in Acromioclavicular Joint Stability: A Cadaveric Biomechanical Study

Background: Acromioclavicular (AC) joint dislocation is evaluated using the radiologically based Rockwood classification. The relationship between ligamentous injury and radiological assessment is still controversial. Purpose/Hypothesis: To investigate how the AC ligament and trapezoid ligament biomechanically contribute to the stability of the AC joint using cadaveric specimens. The hypothesis was that isolated sectioning of the AC ligament would result in increased instability in the superior direction and that displacement >50% of the AC joint would occur. Study Design: Controlled laboratory study. Methods: Six shoulders from 6 fresh-frozen cadavers were used in this study. Both the scapula and sternum were solidly fixed on a customized wooden jig with an external fixator. We simulated distal clavicular dislocation with sequential sectioning of the AC and coracoclavicular (CC) ligaments. Sectioning stages were defined as follows: stage 0, the AC ligament, CC ligament, and AC joint capsule were left intact; stage 1, the anteroinferior bundle of the AC ligament, joint capsule, and disk were sectioned; stage 2, the superoposterior bundle of the AC ligament was sectioned; and stage 3, the trapezoid ligament was sectioned. The distal clavicle was loaded with 70 N in the superior and posterior directions, and the magnitudes of displacement were measured. Results: The amounts of superior displacement averaged 3.7 mm (stage 0), 3.8 mm (stage 1), 8.3 mm (stage 2), and 9.5 mm (stage 3). Superior displacement >50% of the AC joint was observed in stage 2 (4/6; 67%) and stage 3 (6/6; 100%). The magnitudes of posterior displacement were 3.7 mm (stage 0), 3.7 mm (stage 1), 5.6 mm (stage 2), and 9.8 mm (stage 3). Posterior displacement >50% of the AC joint was observed in stage 3 (1/6; 17%). Conclusion: We found that the AC ligaments contribute significantly to AC joint stability, and superior displacement >50% of the AC joint can occur with AC ligament tears alone. Clinical Relevance: The AC ligament plays an important role not only in horizontal stability but also in vertical stability of the AC joint.

High degree of consensus achieved regarding diagnosis and treatment of acromioclavicular joint instability among ESA-ESSKA members

Purpose To develop a consensus on diagnosis and treatment of acromioclavicular joint instability. Methods A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when ≥ 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data. Results A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similar Conclusion A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified. Level of evidence Level V.

Anatomic Reduction is not essential for Good Functional Outcome in Surgical Treatment of Acromioclavicular Dislocation (Quality of the Reduction in Ac Dislocation)

Background: Treatment of displaced acromioclavicular disjunction is not consensual. The goal is to evaluate the concordance between clinical and radiological results in acute displaced acromioclavicular joint dislocation (ACD) at a minimum 1 year’s follow-up. Methods: Fourteen patients underwent open coracoclavicular and acromioclavicular ligament reconstruction by artificial ligament (Acrolig™, Fx Solutions) and twelve underwent arthroscopic coracoclavicular ligament reconstruction by a single paired endobutton (Zip Tight™, Zimmer Biomet). Shoulder function was assessed by an independent examiner with objective and subjective international validated scores. Frontal acromioclavicular displacement was measured all along the follow-up, and reduction quality at last follow-up was assessed frontally and laterally, and globally according to 5 groups of reduction, by 2 examiners. Results: Rockwood classification distribution was: grade 3 (61.6%), grade 4 (30.8%) and grade 5 (15.4%). Mean follow-up was 26.6±8.2 months. All objective and subjective scores were “good” or “very good” at last follow-up (Constant-Murley = 94.1±4.8). Radiologic analysis according to reduction quality showed that anatomic reduction was twice as frequent in the frontal plane (23.1%) as in the sagittal plane (11.5%). Analysis of global reduction quality found 42% anatomic or good reduction, and 58% partial or poor reduction. There were no significant differences in any clinical scores according to reduction quality (on the different views). Comparison between groups “anatomic and good reduction” and “moderate and poor reduction” found no significant differences on any clinical scores neither. Conclusion: Anatomic reduction would not seem to be mandatory for good functional results in displaced acute ACD.

Outcome of fixation of acromioclavicular joint dislocation type-iii with clavicular hook plate

Introduction: Acromioclavicular (AC) joint dislocation is one of the most common shoulder injuries accounting for approximately 9-12% of all shoulder girdle injuries. Rockwood classification of AC joint dislocation is the most widely accepted classification system which classifies the injury into six types. Surgical management with open reduction and fixation with clavicular hook plate without the repair of coracoclavicular ligament has proved to be one of the best treatment options for Type III AC joint dislocations. Methods: Twenty-three patients with Rockwood Type III AC joint dislocation were included in the study. Open reduction was done and the fixation was done with the clavicular hook plate. The functional outcomes were assessed before and two months after the implant was removed using the Constant- Murley Score. Results: A total of 23 patients were included in the study with the mean age of 30.74 years. The plates were removed on an average of 6.43 months and mean follow up was 8.83 months. The functional outcome was assessed using the Constant- Murley Shoulder score. The pain scores were significantly better after the implant removal was done (p= 0.007). The final mean constant score was 74.6 ± 4.11 before removal and 93.91 ± 2.71 after implant removal and all the 23 patient had excellent result (>90 points). Conclusions: The pre-contoured clavicular hook plate has proved to be a good implant option in the fixation of Rockwood Type III AC joint dislocation without the need of any ligamentous repair

Study of clinical outcome of acromioclavicular joint injury type III-VI treated by EndoButton and threads in adults

<p class="abstract"><strong>Background:</strong> Acromioclavicular joint dislocations are common in physically active young adults that too most common in persons who are participating in sports activities. Incidence is more in males who are participating in contact sports like rugby, basketball, hockey. It accounts for 9% of all shoulder injuries. Literature says the incidence is 3-4/1,00,000 population. The aim of the present study was<strong> </strong>to study the functional outcome of acromioclavicular joint after reconstruction of both acromioclavicular and coracoclavicular ligament using endo button system and to provide pain-free, mobile shoulder.</p><p class="abstract"><strong>Methods:</strong> In the present study, 15 patients were selected of age group 20-60 years. Acromioclavicular joint injuries are classified according to Rockwood classification and the findings from the physical examination and anteroposterior and axillary radiographs. All patients were treated as per status of injury level by either conservatively or operatively with open reduction and reconstruction of both ligament by using endo button thread system and its outcomes were assessed clinically and radiologically.<strong></strong></p><p class="abstract"><strong>Results:</strong> Patients were evaluated using American shoulder and elbow score (ASES) score and Constant shoulder score. Average ASES score was 90 (range 68.3-98.3) and constant score was 88 (range 63-96). According to constant score 7 patients had excellent outcome, 6 patients had good outcome, 2 patients had adequate outcome. All patients reported satisfaction with the treatment. The patients were followed upto 6 months.</p><p class="abstract"><strong>Conclusions:</strong> The technique proved to be effective in treating acute. Acromioclavicular joint dislocations (Rockwood type III-VI) with a high degree of patient satisfaction.</p>

Acromioclavicular Joint Trauma

Chapter 10 reviews acromioclavicular joint trauma. The acromioclavicular (AC) joint represents the articulation between the acromion process and lateral clavicle and is a synovial joint stabilized by 3 ligaments. AC joint injuries are most common in active/athletic young adults. The most common injury is AC joint dislocation sustained during contact sports. This injury usually happens from a fall on an outstretched arm. The degree of separation can be evaluated by radiography and, if needed, CT and MRI. The injury is divided into 6 types by the Rockwood classification based on degree of separation of the acromion from the clavicle.

Surgical Outcomes After Fixation of Acromioclavicular Joint Dislocation with Hook Plate and Coracoacromial Ligament Transfer Technique

BACKGROUND: Treatment of acute and chronic acromioclavicular joint dislocations is still controversial. We aimed evaluation of surgical outcomes after using the combined technique with a hook plate and transposition of the coracoacromial ligament in the treatment of acromioclavicular dislocation. CASE PRESENTATION: During two years 4 patients (2 acute and 2 chronic cases) were operated with this technique. Three male and one female with an average 37 (26-43) years old were: three on the right and one of the left side. Rockwood classification was used. The evaluation was done according to Constant score - preoperatively, 3 months after the operation and 3 months after the titanium plate was removed. CONCLUSION: Evaluation of the effectiveness using this combined technique show excellent result in all four patients. No surgical site infection and the favourable cosmetic result were present.