Acromioclavicular joint separation: Retrospective study of non-operative and surgical treatment in 38 patients with grade III or higher injuries and a minimum follow-up of 1 year.

INTRODUCTION: Acromioclavicular (AC) joint separation is a common shoulder injury. When the injury is graded as type III or higher in the Rockwood classification, surgical treatment can be proposed. However, an increasing number of practitioners are shifting back to conservative treatment as it is associated with fewer complications and seemingly close functional outcomes. The aim of our study was to evaluate the functional recovery of operated and non-operated patients with grade III or higher AC joint injuries. Secondarily, the reliability and relevance of the Rockwood classification was evaluated within and between raters. MATERIALS AND METHODS: We did a retrospective two-center study of 38 patients treated between 2014 and 2020. The clinical evaluation involved various functional outcome scores (Constant, QuickDASH, ASES, UCLA, SSV, STT) and a pain assessment (VAS). Return to sports and to work was also documented. The radiological evaluation consisted of Zanca AP and lateral axillary views immediately after the injury and at each radiographic follow-up visit until the final visit. An intra- and inter-rater analysis was also done for the Rockwood classification. RESULTS: There was no significant difference in the functional scores (Constant score surgery group=91, nonoperative group=83; p=0.09) or the pain on VAS at the final assessment. Return to work and to sports was significantly faster in patients treated non-operatively. No complication was found in the non-operated patients, while nine of the operated patients suffered a complication. The inter-rater reliability of the Rockwood classification was found to be poor (kappa=0.08) to fair (kappa=0.35), while the intra-rater reliability was moderate (kappa=0.6) to good (kappa=0.63). DISCUSSION/CONCLUSION: No matter which treatment is used, the functional outcomes and patient satisfaction level a minimum of 1 year after the injury appear to be identical. Thus, surgery should be only for patients whose AC joint is painful 7 days after the injury (VAS>7) and whose function has not improved. For young and athletic patients or for patients who simply want to regain nearly normal function, it is important to remember that the time to return to work and sports is longer with surgical management and to take into consideration the potential postoperative complications. While none of the patients who received the non-operative treatment required a secondary stabilizing surgery, this is a possible recourse. LEVEL OF EVIDENCE: III.

Prospective evaluation of early functional recovery of displaced fractures of the middle third of the clavicle whether operated or not.

INTRODUCTION: Several studies have analyzed the functional recovery after plate fixation of a displaced fracture of the middle third of the clavicle beyond the 6th week. The aim of this study was to assess the early functional recovery in the first 6 weeks, which has not yet been investigated. HYPOTHESIS: Functional recovery in the first 6 weeks after surgical treatment is better than in the first 6 weeks of functional (non-operative) treatment. METHODS: Any patient who had a closed displaced fracture of the middle third of the clavicle - Edinburgh types 2B1 or 2B2 - was informed of the treatment options within a week of their fracture: surgical fixation by anatomic plate or functional treatment. A QuickDASH score was filled out weekly for 6 weeks and at 3 and 6 months. Similarly, the Constant score was determined at 3 and 6 weeks and at 3 and 6 months. Any complications were documented and time to union was determined. RESULTS: Sixty-five fractures in 65 patients were followed for 6 months. Twenty-six patients chose surgical treatment (S) and 39 chose functional treatment (F). The Constant and QuickDASH scores were significantly better in the S group from the 2nd to the 6th week. At 3 weeks, we found a Constant score of 57.7 in group F versus 74.9 in group S (p<0.01) and a QuickDASH of 55.9 in group F versus 27.4 in group S (p<0.001). At 6 weeks, the Constant score was 71.3 versus 86.1 (p<0.001) and the QuickDASH was 28.3 versus 10.6 (p<0.01), respectively. At 3 and 6 months, the recovery was comparable in both groups for these two scores. Return to work was earlier in the S group (34.3 versus 59.7 days; p<0.05). DISCUSSION: This is the first study reporting the functional results during the first 6 weeks after a displaced fracture of the middle third of the clavicle in adults. Further studies should be conducted to better identify target patients for whom fracture fixation may be beneficial. CONCLUSION: This study supports open reduction and internal fixation with an anatomical plate of displaced fractures of the middle third of the clavicle since the functional recovery is better in the first 6 weeks. LEVEL OF EVIDENCE: III; prospective case-control study.

Tips and tricks for end-to-side anastomosis arteriotomies.

Arteriotomy is a critical step during end-to-side anastomosis procedures. However, it is challenging to carry out because of the concentric lamellar structure of blood vessels and the need for clean margins. We performed a review of the literature to identify the advantages and disadvantages of the available arteriotomy methods. The techniques were classified into (1) single-cut or slit arteriotomy (longitudinal and transverse) or (2) excision arteriotomy. The latter techniques can be performed from either outside-in (excision with straight microscissors, curved microscissors, Acland-Banis arteriotomy clamp, micro-arteriotomy scissors, or triangular cutting scissors, and vaporization with Excimer(®) laser) or inside-out (excision with punch/micropunch). Microsurgeons have multiple arteriotomy methods at their disposal. By being familiar with these methods, they can select the most appropriate one for the situation at hand.