Prospective Multicenter Randomized Controlled Trial of Surgical Versus Nonsurgical Treatment for Acute Rockwood Type 3 Acromioclavicular Injury.

Background: Evidence for the superiority of surgical versus nonsurgical treatment of Rockwood type 3 acromioclavicular joint (ACJ) dislocation is still lacking. Hypothesis: It was hypothesized that surgical treatment will outperform nonsurgical treatment. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A prospective randomized trial involving 4 study centers was performed from January 1, 2011, to March 31, 2016. A total of 85 patients with acute Rockwood type 3 ACJ dislocations were allocated randomly to receive either nonsurgical or surgical treatment. A total of 70 patients were treated as allocated, and 8 patients made an early crossover from nonsurgical to surgical treatment, leaving 47 patients treated surgically and 31 patients nonsurgically. All patients were followed up longitudinally, including clinical evaluation using the Constant score and standardized radiographic evaluation, with final follow-up after 2 years. Results: At no follow-up time point was there a significant difference in Constant score between the surgically and nonsurgically treated patients. Radiographic analysis showed not only an inferior coracoclavicular distance at all follow-up points for surgical treatment but also a higher incidence of posttraumatic osteoarthritis and heterotopic ossifications, without any negative clinical correlation. With regard to complications, 1 patient (3%) in the nonsurgical group underwent secondary surgical ACJ stabilization. The revision rate after surgical treatment was 17% (P < .001). Neither primary horizontal instability nor younger age were associated with inferior clinical outcomes after nonsurgical treatment. Conclusion: Surgical treatment of ACJ Rockwood type 3 injuries did not lead to superior functional outcomes. Neither younger age nor horizontal instability were associated with inferior outcomes after nonsurgical treatment. Surgical treatment led to a slower recovery and to higher complication and revision rates. Registration: ISRCTN registry (study ID: ISRCTN92265154).

The ligamentous injury pattern in acute acromioclavicular dislocations and its impact on clinical and radiographic parameters.

BACKGROUND: Acromioclavicular (AC) joint dislocations are classified according to the Rockwood (RW) classification, which is based on radiographic findings. Several authors have suggested magnetic resonance imaging (MRI) for visualization of the capsuloligamentous structures stabilizing the AC joint. The aim of this study was to describe the ligamentous injury pattern in acute AC joint dislocations by MRI and investigate associations with clinical and radiographic parameters. METHODS: This prospective study included 45 consecutive patients (5 women and 40 men; mean age, 33.6 years [range, 19-65 years]) with an acute AC joint separation (RW type I in 5, RW type II in 8, RW type III in 18, and RW type V in 14). All patients underwent physical examination of both shoulders, and clinical scores (Subjective Shoulder Value, Constant score, Taft score, and Acromioclavicular Joint Instability Score) were used to evaluate the AC joint clinically as well as radiographically. Post-traumatic radiography included bilateral anteroposterior stress views and bilateral Alexander views to evaluate vertical instability and dynamic posterior translation. MRI was performed for assessment of the AC and coracoclavicular (CC) ligaments and the delto-trapezoidal fascia. RESULTS: Radiographic and MRI classifications were concordant in 23 of 45 patients (51%), whereas 22 injuries (49%) were misjudged; of these, 6 (13%) were reclassified to a more severe type and 16 (36%), to a less severe type. The integrity of the CC ligaments was found to have a clinical impact on vertical as well as horizontal translation determined by radiographs and on clinical parameters. Among patients with an MRI-confirmed complete disruption of the CC ligaments, 68% showed a radiographic CC difference > 30% and 75% showed complete dynamic posterior translation. Inferior clinical parameters were noted in these patients as compared with patients with intact CC ligaments or partial disruption of the CC ligaments (Constant score of 67 points vs. 49 points [P < .05] and Acromioclavicular Joint Instability Score of 51 points vs. 23 points [P < .05]). The inter-rater and intra-rater reliability for assessment of the ligamentous injury pattern by MRI was fair to substantial (r = 0.37-0.66). CONCLUSION: The integrity of the CC and AC ligaments found on MRI has an impact on clinical and radiographic parameters.

Tendon regeneration and muscle hypotrophy after isolated Gracilis tendon harvesting - a pilot study.

PURPOSE: The gracilis tendon (GT) is a commonly used autologous graft in Orthopaedic surgery. The majority of information on knee function and outcomes after hamstring harvest is related to both semitendinosus and GT harvest. Little is known regarding isolated harvest of a GT. It was hypothesized that isolated GT harvest would lead to altered gait patterns (e.g. augmented anterior-posterior translation or rotation in the tibiofemoral joint) and consequently a higher prevalence of cartilage lesions and meniscal tears in knees. METHODS: GT harvesting was performed on patients with chronic acromioclavicular joint instability without previous knee injuries or surgeries. MRI of both knees and thighs were performed. Knee MRI were evaluated using the Whole-Organ Magnetic Resonance Imaging Score (WORMS). Inter- and intraobserver reliabilities, cross-sectional areas of different muscles, fatty infiltration of the gracilis muscle (GM) and GT regeneration were evaluated. The contralateral limb served as reference. The observers were blinded towards the identity of the patients and the operatively treated side. RESULTS: After a mean time of 44 months after surgery testing was performed on 12 patients. No significant side-to-side differences were found using WORMS, although there was a trend towards increased cartilage lesions after GT harvest (median healthy knee 4.8 and GT harvested knee 7.8 p = 0.086). Inter- and intraobserver repeatability was high with 0.899 (95% confidence interval (CI) 0.708-0.960) and 0.988 (95% CI 0.973-0.995), respectively. A significant hypotrophy of the GM with a mean decrease of 25.3%, 18.4% and 16.9% occurred at 25% (p = 0.016), 50% (p = 0.007) and 75% (p = 0.002) of the length of the femur from distal. No compensatory hypertrophy of other thigh muscles or increased fatty infiltration of the GM was found. Tendon regeneration took place in eight out of 12 patients. In case of regeneration, the regenerated tendon inserted in a more proximal place. CONCLUSION: Isolated harvest of the GT for shoulder procedures did not affect knee MRI significantly indicating therefore in general suitable graft utilization for surgeries outside of the knee. GT regenerated in most patients with just a more proximal insertion and a hypotrophy of the muscle belly.

Isolated gracilis tendon harvesting is not associated with loss of strength and maintains good functional outcome.

PURPOSE: The gracilis tendon is a commonly used autologous graft. Most information on knee function and outcomes after its harvest is related to both semitendinosus- and gracilis tendon harvest. Therefore this study analyzed the effect of isolated gracilis tendon harvest from healthy, uninjured knees on thigh muscle strength and patient reported outcome measures (PROMs). METHODS: Stabilization of the acromioclavicular joint because of chronic instability was performed with autologous gracilis tendon in 12 patients. After a mean of 44 ± 25 months after surgery, isokinetic peak-torque measurements of specific functions of the gracilis muscle were performed: knee flexion in a sitting position (flexion angles 0-90°) and in prone position (flexion angles > 70°), internal tibial rotation and hip adduction. The contralateral limb was control. Knee specific PROMs were collected including IKDC-2000 subjective evaluation form, Lysholm score, the Marx Activity Rating Scale and SF-36 health survey. RESULTS: No significant side-to-side differences were found regarding torque measurements. Excellent results were shown regarding the PROMs, which even in terms of IKDC-2000 (97 vs. 82 points, p = 0.001) exceeded significantly the age- and gender matched reference-data. CONCLUSION: Isolated gracilis tendon harvesting was not associated with loss of strength in knee flexion, internal tibial rotation and thigh adduction. Additionally, good functional outcome as well as excellent knee-specific subjective outcome was found. LEVEL OF EVIDENCE: III.

Primary versus revision arthroscopically-assisted acromio- and coracoclavicular stabilization of chronic AC-joint instability.

BACKGROUND: A gracilis tendon autograft with TightRope-augmentation can be used for arthroscopically-assisted acromioclavicular (AC)- and coracoclavicular (CC-)stabilization of chronic bidirectional AC-joint instability after failed primary treatment. The impact of failed initial treatment on postoperative outcome is unclear. Hence, the purpose of this study was to evaluate it. METHODS: Twenty-seven of 38 patients suffering from chronic AC-joint instability after either failed conservative (group 1) or surgical treatment (group 2) treated in the above-mentioned technique were finally included in this study. The Subjective Shoulder Value, the Constant Score, the Taft Score and the Acromioclavicular Joint Instability Score were used for clinical evaluation. Bilateral anteroposterior stress radiographs and bilateral Alexander views were obtained for radiological evaluation. RESULTS: 14 patients of group 1 [3f/11m; median age 47.6 (range 20.9-57.4) years] could be evaluated after a median follow-up of 24.3 (range 20-31.2) months and 13 patients of group 2 [6f/7m; median age 44.9 (range 24.9-61.0) years] were available after a median follow-up of 28.8 (range 20-33) months. Comparison of clinical score results revealed no significant differences between both groups. The median CC-difference showed no significant difference between the groups [group 1 0.8 (0-10.5) mm, group 2 0.9 (0-4.3) mm]. CONCLUSION: AC- and CC-stabilization of chronic bidirectional AC-joint instability using a gracilis tendon autograft with TightRope-augmentation can be recommended after failed conservative and surgical treatment. STUDY DESIGN: Retrospective cohort study; Level of evidence III.

The Diagnosis and Treatment of Acute Dislocation of the Acromioclavicular Joint.

BACKGROUND: The acromioclavicular joint (ACJ) is one of the more common sites of shoulder girdle injury, accounting for 4-12% of all such injuries, with an incidence of 3-4 cases per 100 000 persons per year in the general population. Current topics of debate include the proper standard diagnostic evaluation, the indications for surgery, and the best operative method. METHODS: This review is based on publications retrieved by a selective literature search. RESULTS: Mechanical trauma of the ACG can tear the ligamentous apparatus that holds the acromion, clavicle, and coracoid process together. Different interventions are indicated depending on the nature of the injury. In recent years, the horizontal component of the instability has received more attention, in addition to its vertical component. Persistent instability can lead to chronic, painful limitation of shoulder function, particularly with respect to working above the head. Surgical stabilization is therefore recommended for high-grade instability of Rockwood types IV and V. Modern reconstruction techniques enable selective vertical and horizontal treatment of the instability and have been found superior to traditional methods, particularly in young athletes. Arthroscopic techniques are advantageous because they are less invasive, do not require removal of implanted material, and afford the opportunity to diagnose any accompanying lesions definitively and to treat them if necessary. Surgery for acute injuries should be performed within three weeks of the trauma. For chronic injuries, additional tendon augmentation is now considered standard treatment. CONCLUSION: High-grade ACJ instability is a complex and significant injury of the shoulder girdle that can cause persistent pain and functional impairment. The state of the evidence regarding its optimal treatment is weak. Large-scale, prospective, randomized comparative studies are needed in order to define a clear standard of treatment.

Dynamic instability of the acromioclavicular joint: A new classification for acute AC joint separation.

BACKGROUND: Acute acromioclavicular (AC) dislocation is classified according to Rockwood (RW). Although of clinical relevance, dynamic horizontal translation (DHT) is not listed in this classification or in frequently used clinical evaluation tools. The aim of this study was (a) to evaluate vertical and horizontal AC joint instabilities and assess their combined occurrence and clinical appearance in a consecutive group of patients, as well as (b) to develop a new classification of acute AC joint dislocation. METHOD: A consecutive group of 61 patients (seven female, 54 male) with a mean age of 34.5 years (18.9-60.1) were included in the study. All patients underwent posttraumatic clinical-Taft Score (TF), Acromioclavicular Joint Instability Score (ACJI), Constant Score (CS), Subjective Shoulder Value (SSV)-and radiological (bilateral anteroposterior stress and bilateral Alexander views) evaluation. RESULTS: According to the RW classification, the following AC dislocations were present: eight (13.1%) type I, nine (14.8%) type II, 22 (36.1%) type III, and 22 (36.1%) type V. Based on the clinical and radiographic results, a new classification is proposed: Type I instabilities show only a partial vertical displacement (≤30% coracoclavicular distance [CCD]) and type II a complete vertical displacement (>30% CCD). Both type I and II are further graded into none or partial (A) and complete DHT (B) as seen on bilateral Alexander views. CONCLUSION: DHT can be found in low-grade instabilities and lead to inferior clinical results in the posttraumatic situation.

Combined arthroscopically assisted coraco- and acromioclavicular stabilization of acute high-grade acromioclavicular joint separations.

PURPOSE AND HYPOTHESIS: Due to high rate of persisting dynamic posterior translation (DPT) following isolated coracoclavicular double-button technique for reconstruction of the acromioclavicular (AC) joint reported in the literature, an additional acromioclavicular cerclage was added to the procedure. The aim of this study was to evaluate the clinical and radiological results of patients with high-grade AC-joint instability treated with a double TightRope technique with an additional percutaneous acromioclavicular cerclage. METHODS: Fifty-nine patients (6 f/53 m; median age 38.3 (range 21.5-63.4 years) who sustained an acute high-grade AC-joint dislocation (Rockwood type V) were treated using the above-mentioned technique. At the final follow-up, the constant score (CS), the subjective shoulder value (SSV), the Taft score (TF) and the acromioclavicular joint instability score (ACJI) as well as bilateral anteroposterior stress views with 10 kg of axial load and bilateral modified Alexander views were obtained. RESULTS: At a median follow-up of 26.4 (range 20.3-61.0) months, 34 patients scored a median of 90 (33-100) points in the CS, 90 (25-100) % in the SSV, 11 (4-12) points in the TF and 87 (43-100) points in the ACJI. The coracoclavicular (CC) distance was 12.1 (6.5-19.8) mm and the CC difference 2.0 (0.0-11.0) mm. Two patients (5.8%) showed a complete DPT of the AC joint, and fourteen patients (41.1%) displayed a partial DPT. The overall revision rate was 11.7%. Two patients presented implant irritation, one patient a recurrent instability, and one patient suffered from a local infection. CONCLUSION: The arthroscopically assisted and image-intensifier-controlled double TightRope technique with an additional percutaneous acromioclavicular cerclage leads to good and excellent clinical results after a follow-up of 2 years. The incidence of persisting dynamic horizontal translation is lower compared to isolated coracoclavicular stabilization. Thus, we recommend using the double TightRope implant with an additional acromioclavicular cerclage. LEVEL OF EVIDENCE: IV.

Quantification of dynamic posterior translation in modified bilateral Alexander views and correlation with clinical and radiological parameters in patients with acute acromioclavicular joint instability.

INTRODUCTION: Classification of AC-joint instability is based on radiologic evaluation of anteroposterior (a.p.) stress views of both shoulders, neglecting the horizontal component of instability. Recent studies have proposed an association of dynamic posterior translation (DPT) and inferior clinical results. The purpose of this study was to quantify DPT in modified Alexander views and correlate it with other radiological and clinical data. MATERIALS AND METHODS: Thirty-two patients (4 f, 28 m, mean age 34.1) with acute AC-joint dislocation (16 = RW III, 16 = RW V) underwent radiological examination including bilateral a.p. stress views with measurement of the coracoclavicular distance (CCD) and bilateral modified Alexander views with different approaches to quantify DPT (overlapping area OAAC, overlapping length OLAC). In addition, the Constant Score, Subjective Shoulder Value, Taft Score (TF), and the Acromioclavicular Joint Instability Score (ACJI) were obtained. RESULTS: In Rockwood (RW) type III injuries, a mean CCD of 15.8 (9.8-22.8) mm, OAAC of 50.9 (0-216.6) mm2, and OLAC of 6.5 (-4.7-17.9) mm were found. RW V patients showed a CCD of 23.1 (13.7-32.0) mm; OAAC 7.0 (0-92.3) mm2; and OLAC -4.8 (-19.6-9.8) mm. Particularly in RW III the CCD, OAAC and OLAC revealed significant correlation with the ACJI (r = -0.64/r = 0.72/r = 0.68, p < 0.05) and TF (r = -0.56/r = 0.68/r = 0.51, p < 0.05). The proposed quantification tools for DPT were found to have a moderate-to-strong correlation with the score results, especially with AC-joint specific scores. RW type V injuries had a moderate correlation with clinical parameters (OAAC with ACJI: r = 0.44, p > 0.05 and OLAC with TF: r = -0.45, p > 0.05). CONCLUSIONS: Measuring the OLAC is a convenient way for quantifying DPT in modified Alexander views. It showed significant correlation with clinical scores, indicating the relevance of DPT in patients with AC-joint injury.

Arthroscopic Reconstruction After Acute Acromioclavicular Separation Injuries.

Acute acromioclavicular (AC)-joint dislocations are common injuries of the shoulder girdle. Surgical repair is indicated for acute high-grade (Rockwood types IV, V, and VI) AC-joint injuries. The best treatment for type III is still controversial, but young and active patients with this type of injury might benefit from a surgical AC-joint stabilization. Surgery should be performed within the first 3 weeks after the injury since the biological healing potential decreases with time. Acute AC-joint separation is diagnosed by clinical examination and radiography. Vertical translation anteroposterior stress views with a 10-kg load are used to grade the injuries. Bilateral lateral stress (Alexander) views are used to evaluate dynamic horizontal translation qualitatively. Arthroscopic techniques for AC reconstruction have become more popular in recent years because they are minimally invasive; they allow treatment of concomitant glenohumeral lesions; and they can be performed in one step, with insertion of implants that do not have to be removed later. The arthroscopically assisted double-button technique with an additional AC cerclage was developed to stabilize the AC joint by internal bracing of the torn ligaments. The procedure consists of the following steps. Step 1: With the patient in the beach-chair position, a 2-cm incision is made on top of the clavicle and posterior and lateral viewing portals as well as an anteroinferior working portal are created. Step 2: With the arthroscope in the lateral portal, the subcoracoid bursa and the base of the coracoid are dissected with a radiofrequency ablation device through the anteroinferior portal. Step 3: Coracoclavicular drilling is done with use of a drill guide and under arthroscopic and image-intensifier control. After overdrilling of the Kirschner wires, Nitinol suture passers are introduced and retrieved via the anteroinferior portal. Step 4: Transclavicular and transacromial drill-holes are established for the AC cerclage. Step 5: The 2 double-button devices are attached to the Nitinol suture passers, and the inferior buttons are shuttled through the clavicle and coracoid and then placed parallel to the coracoid base. Step 6: The sutures are tightened, and an anatomical vertical reduction of the AC joint is achieved. Step 7: A triangular acromioclavicular nonabsorbable cerclage tape is used for horizontal stabilization. Step 8: The clavicular incision is closed in 2 layers, including the repair of the deltotrapezoidal fascia and the arthroscopic portals, in a standard fashion. The combined arthroscopically-assisted and image-intensifier-controlled double-button technique with an additional AC cerclage is a safe procedure that enables an anatomical reduction of the AC joint and yields good to excellent clinical results.

Arthroscopic Glenoid Reconstruction for Chronic Anteroinferior Shoulder Instability Using a Tricortical Iliac Crest Bone Graft.

INTRODUCTION: Arthroscopic glenoid reconstruction using a tricortical iliac crest bone graft is performed to anatomically reconstruct the glenoid and reestablish glenohumeral stability in patients with chronic anteroinferior shoulder instability and substantial osseous defects1-3. STEP 1 PATIENT POSITIONING: Place the patient in the lateral decubitus position and prepare the arm and ipsilateral iliac crest. STEP 2 DIAGNOSTIC ARTHROSCOPY AND PORTAL PLACEMENT: Perform a diagnostic arthroscopy via the posterior portal and establish an anteroinferior, an anterosuperior, and a deep anteroinferior portal. STEP 3 CAPSULOLABRAL COMPLEX RELEASE AND SCAPULAR NECK PREPARATION: Depending on the pathology and morphology of the defect, release the capsulolabral complex from the scapular neck and prepare the glenoid rim and scapular neck with a motorized burr to ensure adequate osseous healing. STEP 4 HARVESTING AND PREPARATION OF THE ILIAC CREST BONE BLOCK: Harvest an autologous tricortical iliac crest bone block from the ipsilateral side and contour it appropriately for an anatomic reconstruction of the glenoid. STEP 5 GRAFT INSERTION AND POSITIONING: Enlarge the passage for the graft through the rotator interval, insert the bone block, and position it anatomically at the scapular neck. STEP 6 GRAFT FIXATION: With the aid of a drill sleeve, temporarily stabilize the graft using Kirschner wires and then definitively attach it to the scapular neck using 2 Bio-Compression screws. STEP 7 CAPSULOLABRAL REPAIR: Reattach the capsulolabral complex to the original glenoid, inferior and superior to the bone block, using 2 knotless suture anchors to complete the anatomic reconstruction of the glenoid. STEP 8 REHABILITATION AND POSTOPERATIVE TREATMENT: Immobilize the arm for 6 weeks postoperatively and limit flexion and external rotation during this time period. RESULTS: Fifteen patients with a mean age of 31.4 years (range, 17 to 49 years) with anteroinferior glenohumeral instability and substantial glenoid defects underwent arthroscopic iliac crest bone-grafting and were prospectively evaluated for an average period of 20.6 months (range, 12 to 65 months)12.

Arthroscopically assisted stabilization of displaced lateral clavicle fractures with coracoclavicular instability.

BACKGROUND: Lateral clavicle fractures associated with partial or complete injury of the coracoclavicular ligaments have traditionally been treated using a variety of open surgical techniques. PURPOSE OF THE STUDY: The aim of this prospective study was the evaluation of the clinical and radiologic outcome of displaced lateral clavicular fractures with coracoclavicular instability treated in an arthroscopic single TightRope technique including an interfragmentary cerclage. METHODS: From 2008 to 2010, 23 patients [8 women and 15 men; mean age 38 (24-63) years] who sustained a displaced lateral clavicular fracture type II according to Neer were included in this study. The follow-up consisted of a complete physical examination of the shoulder including range of motion, the constant score (CS), and the subjective shoulder value (SSV). The radiological follow-up included an anteroposterior stress view with 10 kg of axial load and bilateral axillary views to evaluate the coracoclavicular distance, the clavicular implant position, and healing of the fracture. RESULTS: After a mean follow-up of 23.0 (13-38) months, 20 patients (7 women and 13 men; mean age 38.3 (24-53) years) were available for follow-up. On average, patients achieved 95.1 (60-100) % in the SSV, 88.7 (64-99; contralateral side 91.8 points; p > 0.05) points in the CS. Radiologically, 18 of 20 patients (90 %) displayed a bony healing of the fracture. The average coracoclavicular distance of 11.2 (6-14) mm did not differ significantly from the healthy side [9.9 (8-14) mm]. In six cases (30 %), coracoclavicular ossifications appeared. Two of 20 patients had concomitant glenohumeral lesions (10 %). Two patients had secondary surgery [implant removal (N = 1 local implant irritation); plate osteosynthesis (N = 1 early loss of reduction)]. CONCLUSION: The arthroscopic-assisted and image intensifier-controlled closed reduction and single TightRope fixation with interfragmentary cerclage of displaced lateral clavicular fractures with coracoclavicular instability yields excellent clinical results and is able to recreate stability of the clavicle.

Arthroscopic anatomic glenoid reconstruction using an autologous iliac crest bone grafting technique.

BACKGROUND: Open bone block procedures for glenohumeral stabilization have been used for a long time. With the advancement of arthroscopic techniques and the development of sophisticated instruments and implants, the insertion of the bone block can be performed by an all-arthroscopic approach. The purpose of this study was to evaluate the clinical and radiologic results after an arthroscopic anatomic glenoid reconstruction using an all-arthroscopic, autologous tricortical iliac crest bone grafting technique. MATERIALS AND METHODS: Fifteen patients (1 female and 14 male patients; mean age, 31.4 years [range, 17-49 years]) underwent reconstruction of significant glenoid defects in cases of recurrent shoulder instability by the aforementioned technique. The patients were followed up clinically (range of motion, Constant score, Rowe score, Subjective Shoulder Value, and Western Ontario Shoulder Instability Index) and radiographically (with true anteroposterior and axillary views, as well as 2-/3-dimensional computed tomography [glenoid configuration, signs of graft resorption, bone consolidation, and glenoid index]). RESULTS: After a mean follow-up period of 20.6 months (range, 12-65 months), the Constant score averaged 85.0 points (range, 73-98 points; contralateral side, 89.6 points [range, 78-96 points]), the Rowe score averaged 88.0 points (range, 65-100 points), the Subjective Shoulder Value averaged 84.5% (range, 50%-100%), and the Western Ontario Shoulder Instability Index averaged 76.7% (range, 46%-93%). No recurrent subluxations or dislocations were observed. Radiographically, computed tomography imaging showed a consolidated autograft in all cases. The glenoid index increased from a mean of 0.77 preoperatively to 1.16 immediately postoperatively; at the time of last follow-up, the glenoid index decreased to 1.04. CONCLUSION: The arthroscopic reconstruction of anteroinferior glenoid defects re-creates the pear-shaped anatomy of the anteroinferior glenoid and leads to good to excellent early clinical results.

Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations in a coracoclavicular Double-TightRope technique: V-shaped versus parallel drill hole orientation.

BACKGROUND: The arthroscopically assisted Double-TightRope technique has recently been reported to yield good to excellent clinical results in the treatment of acute, high-grade acromioclavicular dislocation. However, the orientation of the transclavicular-transcoracoidal drill holes remains a matter of debate. HYPOTHESIS: A V-shaped drill hole orientation leads to better clinical and radiologic results and provides a higher vertical and horizontal stability compared to parallel drill hole placement. STUDY DESIGN: This was a cohort study; level of evidence, 2b. METHODS: Two groups of patients with acute high-grade acromioclavicular joint instability (Rockwood type V) were included in this prospective, non-randomized cohort study. 15 patients (1 female/14 male) with a mean age of 37.7 (18-66) years were treated with a Double-TightRope technique using a V-shaped orientation of the drill holes (group 1). 13 patients (1 female/12 male) with a mean age of 40.9 (21-59) years were treated with a Double-TightRope technique with a parallel drill hole placement (group 2). After 2 years, the final evaluation consisted of a complete physical examination of both shoulders, evaluation of the Subjective Shoulder Value (SSV), Constant Score (CS), Taft Score (TF) and Acromioclavicular Joint Instability Score (ACJI) as well as a radiologic examination including bilateral anteroposterior stress views and bilateral Alexander views. RESULTS: After a mean follow-up of 2 years, all patients were free of shoulder pain at rest and during daily activities. Range of motion did not differ significantly between both groups (p > 0.05). Patients in group 1 reached on average 92.4 points in the CS, 96.2 % in the SSV, 10.5 points in the TF and 75.9 points in the ACJI. Patients in group 2 scored 90.5 points in the CS, 93.9 % in the SSV, 10.5 points in the TF and 84.5 points in the ACJI (p > 0.05). Radiographically, the coracoclavicular distance was found to be 13.9 mm (group 1) and 13.4 mm (group 2) on the affected side and 9.3 mm (group 1) and 9.4 mm (group 2) on the contralateral side. The distance of neither the affected side nor the contralateral side differed significantly between both groups (p > 0.05). In group 1, eight patients (53 %) and in group 2 four patients (31 %) revealed signs of dynamic posterior instability (p > 0.05). Clavicular drill hole enlargement was found to be equally distributed in group 1, whereas group 2 displayed a cone-shaped form. CONCLUSION: The Double-TightRope technique yields good to excellent clinical results in both V-shaped and parallel drill hole placement. Partial recurrent vertical and horizontal instability represents a problem in both techniques. So far, no significant differences regarding clinical or radiologic results have been found. Long-term results are needed to reveal possible advantages in terms of clinical and radiologic acromioclavicular stability.

Prevalence and pattern of glenohumeral injuries among acute high-grade acromioclavicular joint instabilities.

BACKGROUND: With increasing numbers of arthroscopically assisted acromioclavicular (AC) joint stabilization procedures has come an increase in reports of concomitant glenohumeral injuries among AC joint separations. The aim of the present study was to evaluate the prevalence, pattern, and cause of glenohumeral pathologies among a large patient population with acute high-grade AC joint instability. MATERIALS AND METHODS: A total of 125 patients (13 women, 112 men) with high-grade AC joint dislocation (6 Rockwood II; 119 Rockwood V) underwent diagnostic glenohumeral arthroscopy before AC joint repair. Pathologic lesions were evaluated for acute or degenerative origin and, if considered relevant, treated all-arthroscopically. RESULTS: Concomitant glenohumeral pathologies were found in 38 of 125 patients (30.4%). Analysis of pathogenesis distinguished different patterns of accompanying injuries: acute intra-articular lesions, related to the recent shoulder trauma, were found in 9 patients (7.2%), degenerative lesions, considered to be unrelated to the recent trauma, were found in 18 (14.4%), and 11 (8.8%) had an unclear traumatic correlation (intermediate group). Within the acute and the degenerative group, affected structures were predominantly partial, articular-sided tears of the anterosuperior rotator cuff, including instabilities of the pulley complex, followed by pathologies of the long head of the biceps and superior labrum anteroposterior lesions. The intermediate group presented mainly with articular-sided partial tears of the subscapularis tendon. CONCLUSIONS: This prospective study showed a high prevalence (30%) of concomitant glenohumeral pathologies, of which some indicate additional surgical therapy and could be missed by an isolated open AC repair. Hence, the arthroscopic approach for AC joint stabilization allows for the diagnosis and treatment of associated intra-articular pathologies.

Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations.

BACKGROUND: The purpose of this study was to evaluate the clinical and radiological results after arthroscopically assisted and image intensifier--controlled stabilization of high-grade acromioclavicular (AC) joint separations using the double TightRope technique with the first-generation implant. HYPOTHESIS: The double TightRope technique using the first-generation implant leads to good clinical and radiological results by re-creating the anatomy of the AC joint. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty-seven consecutive patients (4 women and 33 men; mean age, 38.6 years) who sustained an acute AC joint dislocation grade V according to Rockwood were included in this prospective study. The Subjective Shoulder Value (SSV), the Constant Score (CS), the Taft Score (TS), and a newly developed Acromioclavicular Joint Instability Score (ACJI) were used for final follow-up. Bilateral stress views and bilateral Alexander views were taken to evaluate radiographic signs of recurrent vertical and horizontal AC joint instability. RESULTS: Twenty-eight patients (2 women and 26 men; mean age, 38.8 years [range, 18-66 years]) could be evaluated after a mean follow-up of 26.5 months (range, 20.1-32.8 months). The interval from trauma to surgery averaged 7.3 days (range, 0-18 days). The mean SSV reached 95.1% (range, 85%-100%), the mean CS was 91.5 points (range, 84-100) (contralateral side: mean, 92.6 points), the mean TS was 10.5 points (range, 7-12), and the ACJI averaged 79.9 points (range, 45-100). The final coracoclavicular distance was 13.6 mm (range, 5-27 mm) on the operated versus 9.4 mm (range, 4-15 mm) on the contralateral side (P < .05). Radiographic signs of posterior instability were noted in 42.9% of cases. Patients with evidence of posterior instability had significantly inferior results in the TS and the ACJI (P < .05). Neither coracoid fractures nor early (within 6 weeks postoperatively) loss of reduction due to tunnel malpositioning or implant loosening was observed. CONCLUSION: The combined arthroscopically assisted and image intensifier--controlled double TightRope technique using implants of the first-generation represents a safe technique and yields good to excellent early clinical results despite the presence of partial recurrent vertical and horizontal AC joint instability.

Subjective and objective outcome after revision arthroscopic stabilization for recurrent anterior instability versus initial shoulder stabilization.

BACKGROUND: The value of arthroscopic revision shoulder stabilization after failed instability repair is still a matter of debate. HYPOTHESIS: Arthroscopic revision shoulder stabilization using suture anchors provides equivalent subjective and objective results compared with initial arthroscopic instability repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Twenty consecutive patients who underwent arthroscopic revision shoulder stabilization using suture anchors (group 2) were matched for age, gender, and handedness (dominant or nondominant) with 20 patients who had initial arthroscopic instability repair using the same technique (group 1). At the time of follow-up, a complete physical examination of both shoulders and evaluation with the Rowe score, Walch-Duplay score, Melbourne Instability Shoulder Score, Western Ontario Shoulder Instability Index, and the Subjective Shoulder Value were performed. In addition, standard radiographs (true AP and axillary views) were taken to evaluate signs of osteoarthritis. RESULTS: After a minimum follow-up of 24 months, no recurrent dislocations were observed in either group. The apprehension sign was positive in 2 cases of revision surgery (0 vs 2; P > .05). No significant differences in the Rowe score (89 vs 81.8 points) were found between groups 1 and 2 (P > .05). However, group 2 revealed significantly lower scores in the Walch-Duplay score (85.3 vs 75.5 points), Melbourne Instability Shoulder Score (90.2 vs 73.7 points), Western Ontario Shoulder Instability Index (89.8% vs 68.9%), and Subjective Shoulder Value (91.8% vs 69.2%) (P < .05). Signs of instability arthropathy were found more often in patients with arthroscopic revision surgery (2 vs 5; P > .05). CONCLUSION: Arthroscopic revision shoulder stabilization is associated with a lower subjective outcome compared with initial arthroscopic stabilization. The objective results found in this study may overestimate the clinical outcome in this patient population.

Arthroscopic reconstruction of chronic anteroinferior glenoid defect using an autologous tricortical iliac crest bone grafting technique.

Only a few reports exist on the management of severe anteroinferior glenoid defects in case of recurrent shoulder instability most of them including open approaches. We describe an all-arthroscopic reconstruction technique of the anteroinferior glenoid that includes an autologous iliac crest bone grafting using bio-compression screws and a capsulolabral repair using suture anchors. This technique recreates the bony and soft-tissue anatomy of the anteroinferior glenoid while preserving the integrity of insertion of the subscapularis (SSC) tendon.