A relook at the reliability of Rockwood classification for acromioclavicular joint injuries.

BACKGROUND: Controversies for treatment of acromioclavicular joint injuries in particular type III injuries may be partially attributed to the lack of a standardized method of radiography and measurement technique. Previous studies looking at the Rockwood classification showed poor inter- and intraobserver reliability (Kappa value approximately 0.20-0.50). We hypothesized that the use of unilateral instead of bilateral acromioclavicular joint radiographs was the cause of this finding. In this article, we standardized the methodology to perform the radiograph and to measure the coracoclavicular distances. We designed the study to focus on the reliability of differentiating type III and type V injuries. METHODS: A standardized radiographic protocol for bilateral Zanca view was established in our institution. All patients who underwent this radiographic examination over a 3-year period were reviewed. Radiographs of 55 patients with significant (type III or V) injury met the inclusion criteria. For the interobserver reliability, a retrospective radiographic review was performed by 6 orthopedic surgeons and graded as either type III or V. For intraobserver reliability, a similar process was repeated by 3 observers after a period of 6 weeks. RESULTS: Going by the majority agreement of the 6 reviewers, there were 34 type III injuries and 19 type V injuries. The Fleiss kappa for interobserver reliability was calculated to be 0.624. The Cohen kappa for intraobserver reliability was calculated to be 0.696. DISCUSSION: The use of a standardized radiographic protocol-taking bilateral Zanca views on the same radiographic plate-would help eliminate a significant amount of variability and improve the reliability of classifying acromioclavicular joint injuries using the Rockwood classification, which uses a relative measure to the contralateral site as its definition criteria. Other possible sources of poor reliability may include the masking of injuries by muscle spasm, resulting in a misdiagnosis of a high-grade injury as a lower-grade one and the possible need to subclassify type III injuries. CONCLUSION: Reliability of the Rockwood classification can be improved through the use of a standardized radiographic protocol to improve the detection of vertical instability. Similar to Rockwood dividing up Tossy grade 3 injuries when he noted the differential outcome and intervention, Rockwood type III injuries would likely require further subclassification as it remains an anomalous tool with high variability. Further studies are required to understand the pathologic basis of transition of type III into type V injury.

Arthroscopic Bankart repair using knot-tying versus knotless suture anchors: is there a difference?

PURPOSE: To compare the clinical outcome between the use of knotless sutures versus knot-tying sutures in arthroscopic Bankart repairs. METHODS: Between January 2007 and January 2011, 87 patients who underwent arthroscopic Bankart repair with the use of knot-tying suture anchors or knotless suture anchors were evaluated, with 45 patients in the knot-tying suture group and 42 patients in the knotless group. Patients were assigned to either group, with odd-numbered patients going to the knot-tying suture arm and even-numbered patients assigned to the knotless arm. Outcomes included the Constant score, the visual analog scale (VAS) score, patient satisfaction score, and range of motion in forward flexion and external rotation with the arm in adduction. Redislocations or subluxations with the 2 techniques was also studied. RESULTS: Both groups showed a statistically significant improvement between the preoperative and postoperative VAS scores and Constant scores. In the knot-tying suture group, the VAS score improved from 2.5 ± 2.3 to 0.7 ± 0.5 (P < .05) and the Constant score improved from 64 ± 7 to 92 ± 10 (P < .05). In the knotless group, the VAS score improved from 2.8 ± 2.5 to 0.9 ± 0.6 (P < .05), and the Constant score improved from 62 ± 6 to 89 ± 9 (P < .05). The patient satisfaction scores were 6.9 and 7.1 for the knot tying and knotless groups, respectively. No statistically significant differences were found when comparing the outcomes between the 2 groups. The change in the range of forward flexion and external rotation was also similar in the 2 groups. There was also no difference in recurrence or redislocation rates. CONCLUSIONS: Both the knot-tying and knotless suture anchors groups showed statistically significant and similar improvement in VAS and Constant scores. Both anchors provided reasonable outcomes. The knotless suture anchor is a good alternative to knot-tying suture anchors so that arthroscopic Bankart repairs can be performed without knot tying. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Single Working Portal Technique for Knotless Arthroscopic Bankart Repair.

Arthroscopic Bankart repair is widely accepted as the method of choice in restoring the labrum to the glenoid rim. It has been shown to have comparable outcomes with open stabilization. This usually involves the use of 2 portals anteriorly: one anterosuperior accessory portal and another anteroinferior working portal. The aim of this Technical Note is to present a simple and reproducible technique for Bankart repair using a single working portal anteriorly without an accessory portal.