Comparison of Conservative and Surgical Treatment of Grade III Acromio-Clavicular Dislocation

Objectives: To compare the mean of constant score between conservative and surgical treatment in patients with Grade-III acromio-clavicular dislocation. Design: This was an RCT (randomized controlled trial). Study Settings: It was conducted at the Orthopedic Department of Sir Ganga Ram Hospital Lahore over 1 year from July 2020 to June 2021. Study Procedure: This study involved 94 both male and female patients aged between 18-60 years presenting in orthopedic emergency with Grade-III AC dislocation. These patients were assigned into two treatment groups randomly. Patients in Group-A were managed conservatively while those in Group-B were managed surgically with hook plate. Outcome variable was functional shoulder outcome which was assessed after 6 weeks of treatment using constant score. An informed written consent was gained from every patient. Results: The mean age of the patients was 29.9±9.5 years. Majority (n=44, 46.8%) of the patients were young and were aged between 18-30 years followed by 31-40 years (36.2%) and 41-50 years (17.0%). There were 89 (94.7%) male and 5 (5.3%) female patients in the study group with a male to female ratio of 17.8:1. The mean BMI of these patients was 25.2±2.2 Kg/m2. Right side was more frequently involved (54.3%) as compared to the left side (45.7%). Upon follow-up, the mean constant score was significantly higher in patients treated surgically as compared to conservative treatment (86.72±6.75 vs. 67.43±8.93; p-value<0.001). Similar substantial difference was observed through different subgroups based on patient’s age, gender, BMI and side involved. Conclusion: Surgical treatment of patients with Grade-III acromioclavicular dislocation was associated with better functional shoulder outcome as compared to conservative treatment and should be preferred in future practice if there is no contraindication to surgery. Keywords: Grade-III AC Dislocation, Conservative Treatment, Surgical Treatment, Shoulder Function

Clinical outcomes of bending versus non-bending of the plate hook in acromioclavicular joint dislocation

Background: We aimed to assess the effect of plate hook bending in treatment of acromioclavicular (AC) dislocation by analyzing clinical and radiological results according to the angle of the plate hook (APH).Methods: This was a retrospective, observational, case-control study including 76 patients with acute AC joint dislocation that were divided into two groups according to treatment with bent or unbent plate hook. The visual analog scale (VAS), the American Shoulder and Elbow Surgeons (ASES) shoulder score, and range of motion (ROM) were evaluated as clinical outcomes. Comparative coracoclavicular distance (CCD) was measured to evaluate radiological outcomes.Results: While the VAS and ASES of the bending group at 4 months after surgery were significantly higher (P=0.021, P=0.019), the rest of those and ROM showed no significant difference. The initial CCD decreased from 183.2%±25.4% to 114.3%±18.9% at the final follow-up in the bending group and decreased from 188.2%±34.4% to 119.1%±16.7% in the non-bending group, with no statistical difference (P=0.613). The changes between the initial and post-metal removal CCD were 60.2%±11.2% and 57.3%±10.4%, respectively, with no statistical difference (P=0.241). The non-bending group showed greater subacromial osteolysis (odds ratio, 3.87). Pearson’s coefficients for the correlation between APH and VAS at 4 months after surgery and for that between APH and ASES at 4 months after surgery were 0.74 and –0.63 (P=0.027 and P=0.032), respectively.Conclusions: The APH was associated with improved postoperative pain and clinical outcomes before implant removal and with reduced complications; therefore, plate hook bending is more useful clinically during plate implantation.

New System for the Classification of Epiphyseal Separation of the Coracoid Process: Evaluation of Nine Cases and Review of the Literature

Objectives and Design. Epiphyseal separation of the coracoid process (CP) rarely occurs in adolescents. In this retrospective case series, we reviewed the data of nine patients treated at our center and those of 28 patients reported in the literature. This injury can be classified into three types according to the injured area: Type I, base including the area above the glenoid; Type II, center including the coracoclavicular ligament (CCL); and Type III, tip with the short head of the biceps and coracobrachialis, as well as the pectoralis minor. Patients/Participants. A total of 37 patients were included in the analysis. Data on sex, age, cause and mechanism of injury, separation type, concomitant injury around the shoulder girdle, treatment, and functional outcomes were obtained. Main Outcome Measurements and Results. Type I is the most common type. The cause of injury and associated injury around the shoulder girdle were significantly different between Type I, II, and III fractures. The associated acromioclavicular (AC) dislocation and treatment were significantly different between Type I and III fractures. Our new classification system reflects the clinical features, imaging findings, and surgical management of epiphyseal separation of the CP. Type I and II fractures are mostly associated with AC dislocation and have an associated injury around the shoulder girdle. Type III fractures are typically caused by forceful resisted flexion of the arm and elbow. Although the latter are best managed surgically, whether conservative or surgical management is optimal for Type I and II fractures remains controversial. Conclusions. We noted some differences in the clinical characteristics depending on the location of injury; therefore, we aimed to examine these differences to develop a new system for classifying epiphyseal separation of the CP. This would increase the clinicians’ awareness regarding this injury and lead to the development of an appropriate treatment.

Late diagnosis of subcoracoid type 6 AC dislocation: A case report

Acromioclavicular (AC) dislocation is a common type of shoulder injury. Although the incidence of acromioclavicular dislocation is frequent, there are different opinions regarding the treatment. Many different techniques have been proposed for the surgical treatment of AC dislocations, but all these methods have been questioned from different angles, and the gold standard in terms of treatment has not yet been determined. There are six types described by Rockwood et al. and type 6 has two types: subacromial and subcoracoid. Subcoracoid AC Type 6 dislocations are seen very rarely and difficult to diagnose in initial clinical findings or can be simply overlooked due to associated more serious injuries which take more attention. The mechanism of injury of a type 6 AC dislocation is hyperabduction and external rotation of the shoulder. A small number of type 6 subcoracoid AC dislocations have formerly been reported and apart from one case all of them were acutely diagnosed and treated with open reduction and internal fixation. In this paper, we report a case of late diagnosis of subcoracoid type 6 AC dislocation, along with its rare and previously unreported surgical management.

The Rockwood classification in acute acromioclavicular joint injury does not correlate with symptoms

Purpose: Rockwood classified acromioclavicular (AC) joint injuries by displacement of the joint on radiographs. This classification has driven the management dogma of acute AC dislocation. The correlation between Rockwood grade and symptoms has not been described in acute injury. This study assesses that relationship. Methods: This series included 77 patients with acute AC joint injury (<6 weeks), treated between 2006 and 2015. Objective and patient-reported measures enabled correlation between clinical measures and Rockwood grade. Results: The mean age was 32 years (±11.86; range 17–59 years); 88% were male. Forty-four per cent were professional athletes and 43% suffered injury during rugby. The mean time from injury to presentation was 2 weeks (±1.64; range 0–5 weeks). There was poor correlation between Rockwood classification and pain (visual analogue scale) ( rs = 0.05; p = 0.752). Poor correlation was noted between Rockwood grade and functional deficit (elevation ( rs = 0.18; p = 0.275), abduction ( rs = 0.19; p = 0.246) and strength ( rs = 0.09; p = 0.579) vs. contralateral side). Oxford and Constant scores did not correlate with Rockwood grade ( rs = 0.13; p = 0.972 and 0.01; p = 0.448, respectively). Conclusion: The Rockwood grade does not correlate with clinical symptoms in acute AC joint injury. Previous evidence demonstrates the Rockwood classification’s limitations in predicting the structures injured. Therefore, the reliability of using the Rockwood grade as a decision-making tool in the management of acute AC joint dislocation is unclear.

Atraumatic Acromioclavicular Dislocation: A Case Report and Review of the Literature

Acromioclavicular dislocation (AC dislocation) is a common injury of the shoulder. In contrast to a traumatic cause, nontraumatic dislocation is very rare. We report on a 17-year-old female that presented with voluntary recurrent dislocation of the right AC joint followed by recurrent pain without instability of the ipsilateral shoulder. Clinical examination showed crepitation as well as palpitation pain and dislocation of the AC joint. There were no symptoms of Marfan or Ehlers-Danlos syndrome as other joint examinations were also negative for hypermobility. Considering age as well as minor complaints, nonoperative treatment by postural therapy without taping was recommended. After one year, the patient experienced fewer symptoms and she was able to participate in daily activities.

Epidemiology of Isolated Acromioclavicular Joint Dislocation

Background. Acromioclavicular (AC) joint dislocation is a common shoulder problem. However, information about the basic epidemiological features of this condition is scarce. The aim of this study is to analyze the epidemiology of isolated AC dislocation in an urban population.Materials and Methods. A retrospective database search was performed to identify all patients with an AC dislocation over a 5-year period. Gender, age, affected side and traumatic mechanism were taken into account. X-rays were reviewed by two of the authors and dislocations were classified according to the Rockwood’s criteria.Results. A total of 108 patients, with a mean age of 37.5 years were diagnosed with AC dislocation. 105 (97.2%) had an isolated AC dislocation, and 3 (2.8%) were associated with a clavicle fracture. The estimated incidence was 1.8 per 10000 inhabitants per year and the male-female ratio was 8.5 : 1. 50.5% of all dislocations occurred in individuals between the ages of 20 and 39 years. The most common traumatic mechanism was sport injury and the most common type of dislocation was Rockwood type III.Conclusions. Age between 20 and 39 years and male sex represent significant demographic risk factors for AC dislocation.