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.

Posterior Ligament-Bone Injury Classification and Severity Score: A Novel Approach to Predict the Failure of Anterior-only Surgery for Subaxial Cervical Facet Dislocations.

STUDY DESIGN: Clinical case series. OBJECTIVE: The aim of this study was to propose a novel posterior ligament-bone injury classification and severity (PLICS) score system that can be used to reflect the severity of subaxial cervical fracture dislocations (SCFDs) and predict the failure of anterior-only surgery; and to measure the intraobserver and interobserver reliability of this system. SUMMARY OF BACKGROUND DATA: The approach selection for SCFDs is controversial. Although the anterior approach is familiar for most surgeons, postoperative hardware failure and/or delayed cervical deformity is a nonnegligible complication. METHODS: Ten patients were randomly selected for intraobserver reliability evaluation on two separate occasions, one month apart. Another 30 patients were randomly selected, and the interobserver reliability was measured by comparing results of each case between each reviewer and averaging. To analyze the difference in the PLICS score, 354 patients fulfilled the follow-up were divided into stable and unstable groups according to whether radiologically stable was observed during follow-up. RESULTS: For the intraobserver reliability, the mean intraclass correlation coefficient for the 10 reviewers was 0.931. For the interobserver reliability, the mean interobserver correlation coefficient for the three elements was 0.863. Among 16 patients with PLICS score ≥7, two patients in the stable group manifested with severe injury of the posterior ligamentous complex (PLC); extremely unstable lateral mass fractures with or without severe injury of PLC were detected in the 14 patients of the unstable group. CONCLUSION: The proposed PLICS score system showed excellent intraobserver and interobserver reliability. When a PLICS score is >7 or 7 accompanied by extremely unstable lateral mass fractures, the risk of postoperative failure after an anterior-only reconstruction is high and supplemental posterior strengthening can be considered.Level of Evidence: 4.

Surgery improves the clinical and radiological outcome in Rockwood type IV dislocations, whereas Rockwood type III dislocations benefit from conservative treatment.

PURPOSE: Despite the available classifications, diagnostics and treatment of acute acromioclavicular joint (ACJ) injuries are still vague and challenging for trauma and shoulder surgeons. This study aimed to evaluate the dynamic radiographic as well as clinical outcome of operatively and conservatively treated Rockwood (RW) type III and IV ACJ dislocations. MATERIALS AND METHODS: All patients with RW type III and IV ACJ dislocations between 2009 and 2016 (n = 226) were included in this retrospective data analysis with a prospective follow-up examination. According to their injury classification, patients were subdivided in an operative and conservative treatment group. Examiner blinded clinical evaluation including the constant score (CS), American shoulder and elbow surgery (ASES) score, the acromioclavicular joint instability (ACJI) score, visual analog scale (VAS), bilateral force measurements, and posttraumatic/postsurgical sequelae were assessed. Fluoroscopic evaluations including dynamic stability assessment with functional axillary views were performed for every patient. RESULTS: For follow-up examination (mean 4.8 years ± 0.3 SEM) 56 patients (29 RW type III, 27 RW type IV) were available. In patients with RW type III ACJ dislocations [operative (n = 10); conservative (n = 19)] prolonged duration of treatment was seen in operatively treated patients (p < 0.05). Clear improvement could be shown for the ACJI score (p < 0.05) and coracoclavicular (CC) and acromioclavicular (AC) distance (p < 0.05) in the operative group. In patients with RW type IV ACJ dislocations [operative (n = 18); conservative (n = 9)] superior clinical results were found in operated patients with highly significant differences for the ACJI score (p < 0.001). Radiographic dynamic horizontal analysis showed nearly normalized anteroposterior translation in operated patients (p < 0.05). No differences were found regarding arthroscopic or open procedures. CONCLUSION: Accurate diagnostics including sufficient dynamic stability assessment with functional axillary views are strongly advised for patients with ACJ dislocations. Conservative treatment should be recommended for patients with RW type III ACJ dislocations, due to shorter duration of treatment with good clinical results but lacking operative risks. In patients with RW type IV ACJ dislocations, surgical treatment is recommended because of superior clinical and radiological results. LEVEL OF EVIDENCE: Level III.

The Bony Bankart: Clinical and Technical Considerations.

Fractures of the anteroinferior aspect of the glenoid rim, known as a bony Bankart lesions, can occur frequently in the setting of traumatic anterior shoulder dislocation. If these lesions are large and are left untreated in active patients, then recurrent glenohumeral instability due to glenoid bone deficiency may occur. Therefore, the clinician must recognize these lesions when they occur and provide appropriate treatment to restore physiological joint stability. This article aims to provide an overview focusing on clinical and technical considerations in the diagnosis and treatment of bony Bankart lesions.

Treatment of closed subtalar joint dislocation: A case report and literature review.

Subtalar dislocation is defined as a separation of the talocalcaneal and talonavicular articulations, commonly caused by high-energy mechanisms, which include falls from height, motor vehicle crashes, and twisting leg injuries. The dislocations are divided into medial, lateral, anterior, and posterior types on the basis of the direction in which the distal part of the foot has shifted in relation to the talus. The most common type is medial dislocation resulted from inversion injury. Subtalar dislocation may accompany with other fractures. Physical examination must be performed carefully to assess for neurovascular compromise. Most of the subtalar dislocations can be treated with closed reduction under sedation. If this is not possible, open reduction without further delay should be conducted. After primary treatment, X-ray and computed tomography scan should be performed to evaluate the alignment and the fractures. We report a 37-year-old male patient sustained a subtalar dislocation without any bony injury when he was playing football. The patient was successfully treated by closed reduction, and a good alignment was observed at the last follow-up. The pathogenesis and treatment method of this case were analyzed, and the related literature were reviewed, which provided a reference for future clinical treatment.

New Classification and Its Value Evaluation for Atlantoaxial Dislocation.

OBJECTIVE: To introduce the TOI classification system (the Traction reduction type [T type], Operation reduction type [O type], and Irreducible type [I type] classification system) and to determine the interobserver and intraobserver reliability of the TOI classification system. METHODS: Based on the characteristics of atlantoaxial dislocation (AAD), AAD was divided into Traction reduction type (T type), Operation reduction type (O type), and Irreducible type (I type). The analysis of interobserver and intraobserver agreements was done using kappa statistics. From July 2016 to January 2019, 213 AAD patients were retrospectively studied at four hospitals. Plain radiographs including extension and flexion views and three-dimensional CT images were obtained. Twenty independent observers, including eight experienced spine specialists and 12 orthopaedic fellows from four different residency training hospitals, completed the survey. RESULTS: The classification of the TOI system was based on etiology, the course of the disease, flexion-extension X-rays, three-dimensional CT reconstruction, and curative effects of skull traction. Flexion-extension X-rays demonstrating a successful reduction of the dislocated atlantoaxial joint and three-dimensional CT images showing osseous fusion of atlantoaxial facet joints and cervical traction reveal characteristics of T-type. Furthermore, this type can be divided into two subtypes, T1 and T2, according to the etiology and course of the disease. Unsatisfactorily reduction after 1-2 weeks of strict cervical traction, no reduction shown on flexion-extension X-rays, and no destruction or boneless fusion of atlantoaxial facet joints demonstrated in three-dimensional CT images are characteristics of type O. Atlantoaxial facet joint showing bone fusion or failure of reduction after cervical traction or three-dimensional CT images showing failure of surgical release are characteristics of type I. Interobserver and intraobserver reliability of the TOI classification system were moderate (κ = 0.543) and substantial (κ = 0.658), respectively. Interobserver and intraobserver reliability of the treatment choice were moderate (κ = 0.568) and substantial (κ = 0.675), respectively. There were no significant differences in the interobserver and intraobserver reliability between experienced spine specialists and fellows for all κ-values (P > 0.05). CONCLUSIONS: The TOI classification system had satisfactory reliability and, therefore, can be applied clinically and used by less experienced surgeons. We believe TOI can help surgeons choose appropriate treatment strategies.

Surgical techniques for management of acromioclavicular joint separations: review and update for radiologists.

Imaging plays a central role in the postoperative management of acromioclavicular (AC) joint separations. There are more than 150 described techniques for the surgical management of AC joint injuries. These procedures can be categorized as varying combinations of the following basic techniques: a) soft-tissue repair, b) trans-articular AC joint fixation, c) coracoclavicular (CC) fixation, d) non-anatomic reconstruction of the CC ligaments, e) anatomic reconstruction of the CC ligaments, f) distal clavicle resection, and g) dynamic muscle transfer. The goals of this article are to describe the basic techniques for the surgical management of AC joint separations with an emphasis on technique-specific complications and postoperative imaging assessment.

Improved identification of unstable acromioclavicular joint injuries in a clinical population using the acromial center line to dorsal clavicle radiographic measurement.

BACKGROUND: Accurate classification and subsequent management of acromioclavicular (AC) joint injuries remains a contentious topic. The updated Rockwood classification acknowledges "stable IIIA" and "unstable IIIB" injuries, a watershed accepted by ISAKOS and important in guiding clinical management. Traditionally, the coracoclavicular distance is used to classify these injuries, despite well-documented limitations. This study aimed to evaluate displacement in AC joint injuries by measuring both coracoclavicular (CC) distance and the newly proposed acromial center line to dorsal clavicle (AC-DC) distance, in a cohort of patients, and correlate the results between the 2 measurements and relationship to Rockwood grade. MATERIALS AND METHODS: Ninety consecutive cases of AC joint injury were evaluated radiographically for Rockwood classification, CC distance on anteroposterior radiographs, and AC-DC distance on Alexander view radiographs. Inter- and intraobserver reliability for each measurement was calculated as well as correlation between the 2 measurement types and the degree to which each measurement accurately represented the Rockwood classification. RESULTS: Although both CC and AC-DC measurements showed very high inter- and intraobserver reliability, the CC distance systematically underestimated the degree of AC joint displacement when compared with the AC-DC measurement as the severity of injury increased, particularly in the presence of posterior horizontal displacement such as that seen in Rockwood IV injuries. CONCLUSION: The AC-DC measurement and use of the Alexander view provides the clinician with a more realistic appreciation of true AC joint displacement, especially in defining watershed cases (ie, IIIA/IIB/IV) and may better inform the decision-making process regarding management options and recommendations.

Ratio of dislocation types of the proximal interphalangeal joint of the fingers: A new classification system for initial therapy.

BACKGROUND: We proposed a new system named the sagittal, coronal, axial, rotational and fracture (SCARF) classification, which can simply explain any condition of proximal interphalangeal (PIP) joint dislocations of the fingers. The purpose of this study was to verify that this classification would contribute to management of PIP joint dislocations at the initial therapy. We determined ratios of five factors in PIP dislocations with SCARF by interpreting radiographs and assessed the interobserver and intraobserver variability. METHODS: In total, 68 fingers in 67 consecutive patients were studied. The SCARF classification is composed of five factors: (1) sagittal plane displacement is rated by dorsal (D), volar (V), or neutral (N); (2) coronal plane displacement, by ulnar (U), radial (R), or neutral (N); (3) axial force, by compression (C), traction (T), or no (N); (4) rotational displacement, by supine (S), prone (P), or neutral (N); and (5) fracture concomitance, by minus (-) or plus (+). The row of the five characters explains each condition of PIP joint dislocations. Interobserver and intraobserver variability was determined after six orthopedic surgeons independently classified the same radiographs twice. RESULTS: All 68 dislocations were classified into 14 types, unless fracture concomitance was considered. The most common type was DUNN (35%). In coronal plane displacements, the two ulnar fingers showed a higher tendency to the ulnar position. Ring finger fracture concomitance was higher than in middle fingers or little fingers. In interobserver analysis, mean kappa coefficient for each factor was 0.63, 0.75, 0.68, 0.33, and 0.84, respectively. In intraobserver analysis, that was 0.73, 0.79, 0.71, 0.41, and 0.81, respectively. CONCLUSIONS: Even other than hand specialists can specify the type of every PIP dislocation by using the SCARF classification and will have better understanding of the disorder. It would contribute to management of PIP dislocations at the initial therapy. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Trauma to the medial ray of the foot: A classification of patterns of injury and their management.

AIMS: Fractures and dislocations of the midfoot are relatively uncommon but can be life changing injuries. Within the literature, there has been scant specific reference to the identification and management of medial ray injuries in midfoot trauma. Moreover, it is appreciated that these injuries are associated with poor outcomes. We aim to clearly define these injury characteristics and demonstrate fixation techniques. PATIENTS AND METHODS: A retrospective review of the case notes and imaging was conducted for operatively treated midfoot injuries between January 2013 and January 2018. RESULTS: 161 patients were identified, 31 of these with imaging and operative diagnosis suggestive of medial ray injury. Studying these 31 injuries revealed five patterns of injury. CONCLUSION: When treating midfoot trauma, it is important to fully understand the injury pattern as this dictates the principles and techniques of fixation. Identification and knowledge of these five injury patterns will aid surgeons in future management of these injuries and may improve treatment outcomes.

Yang's Classification of Juvenile TMJ Anterior Disc Displacement Contributing to Treatment protocols.

This study aims to establish a new staging system of temporomandibular joint (TMJ) anterior disc displacement (ADD) and evaluate its role in guiding the treatment plan. A consecutive sample of 522 juvenile patients (780 joints) diagnosed as ADD based on magnetic resonance imaging (MRI) was included and analyzed. 674 joints received TMJ treatments according to our staging system, while 106 joints rejected any treatment; only for follow-up. The outcomes were judged according to our success criteria. The prognosis of our staging system was also evaluated in comparison to Wilkes classification. Kaplan-Meier survival analysis showed that significant stratifications of the ameliorative rate were found at all subgroups within any two stages in our staging system, except for subgroups between stages 0 and 1, stages 2 and 3, and stages 3 and 4. After analyzing the interactions between different candidate prognostic factors in a Cox model, the relative risks of deterioration of ADD included treatment methods (HR = 42.94, P < 0.0001), disease course (HR = 0.98, P = 0.0019), stages of ADD (HR = 3.81, 9.62, 12.14, P = 0.016, 0.000,0.000 respectively for stage 2, stage 3 and stage 4) and the interaction between ADD stages and treatment methods. The C index of this model was 0.87. The new staging system of TMJ ADD appears reliable, and benefits to making treatment planning and predicting the prognosis.

Another Classification of First Metatarsophalangeal Joint Dislocation-Type 3: Review and Case Description of the Plantar Dislocation.

Plantar dislocation of the first metatarsophalangeal joint is a possible, albeit rare, injury to the foot. The mechanism has been attributed to a hyperflexion motion, with the hallux situated plantar to the first metatarsal head. In this article, we provide a case example of an open, plantar dislocation of the first metatarsophalangeal and perform a literature review of this rare injury. Based on x-ray analysis of the published cases, the sesamoids may or may not dislocate with the phalanx based off of the local capsuloligamentous anatomy. As a result, a modified Jahss classification (type 3A and type 3B) has been proposed to amend the existing system, adding plantar dislocations of the first metatarsophalangeal without (type 3A) and with (type 3B) sesamoid dislocation.

The Trapezium Dislocation: Case Presentation, Review of the Literature, Radiographic Analysis, Proposed Classification, and Treatment.

BACKGROUND: Trapezium dislocations are rare injuries. METHODS: A PubMed search of the term "trapezium dislocation" was conducted. Publications reporting a complete trapezium dislocation were included in the review. RESULTS: The PubMed search resulted in 168 results. Fourteen publications reporting on 16 complete trapezium dislocations met inclusion criteria. A case of delayed diagnosis of a trapezium dislocation is presented. The literature is reviewed for pertinent clinically relevant information with respect to trapezium dislocations. A systematic method for radiographic analysis of trapezium dislocations and classification are described, and a treatment algorithm is presented. CONCLUSIONS: Trapezium dislocations are infrequent injuries with few cases reported in the literature. Given the rarity of this injury, diagnosis and appropriate treatment may be delayed due to difficulty in recognition. Using the described method of radiographic analysis, delayed diagnosis may be avoided with implementation of timely treatment.

Open Reduction and Tunneled Suspensory Device Fixation Compared with Nonoperative Treatment for Type-III and Type-IV Acromioclavicular Joint Dislocations: The ACORN Prospective, Randomized Controlled Trial.

BACKGROUND: Nonoperative management of complete acromioclavicular (AC) joint dislocation has yielded reasonable results, although patients may report dissatisfaction with the outcome. The purpose of this prospective, randomized, controlled trial was to compare patient outcome following nonoperative care versus operative treatment with open reduction and tunneled suspension device (ORTSD) fixation for acute, type-III or IV disruptions of the AC joint. METHODS: Sixty patients aged 16 to 35 years with an acute type-III or IV disruption of the AC joint were randomized to receive ORTSD fixation or nonoperative treatment, following a power analysis to determine sample size. Functional outcomes were assessed with use of the Disabilities of the Arm, Shoulder and Hand (DASH) as the primary outcome measure and the Oxford Shoulder Scores (OSS) and Short Form (SF-12) as secondary outcome measures at 6 weeks, 3 months, 6 months, and 1 year after treatment. Reduction was evaluated with use of radiographs. Any complications were noted at each assessment. The economic implication of each treatment was evaluated. RESULTS: ORTSD and nonoperative groups were similar with regard to demographics at baseline. The mean degree of radiographic displacement was significantly less in patients following ORTSD fixation (1.75 mm) compared with patients who received nonoperative treatment (10.61 mm, p < 0.0001). At 1 year postoperatively, the mean DASH score was 4.67 in the nonoperative treatment group and 5.63 in the ORTSD group, and the mean OSS was 45.72 and 45.63, respectively. Patients managed with ORTSD fixation had inferior DASH scores at 6 weeks (p < 0.01). There were 5 patients who experienced failed nonoperative treatment and subsequently underwent a surgical procedure. ORTSD fixation (£3,359.73) was associated with significantly higher costs than nonoperative treatment (£796.22, p < 0.0001). CONCLUSIONS: ORTSD fixation confers no functional benefit over nonoperative treatment at 1 year following type-III or IV disruptions of the AC joint. Although patients managed nonoperatively generally recovered faster, a substantial group of patients remained dissatisfied following nonoperative treatment and required delayed surgical reconstruction. We were unable to identify any demographic or injury-related factors that predicted a poorer outcome in these patients. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Dislocation.

BACKGROUND: The purpose of this study was to evaluate mid- and long-term clinical and radiologic outcomes of arthroscopic coracoclavicular ligament reconstruction (ACCLR) with an artificial ligament for acute dislocation of the acromioclavicular joint (ACJ). METHODS: Twelve male patients (average age at the time of surgery: 40.8 years, range: 21-64 years) underwent ACCLR with an artificial ligament for acute dislocation of the ACJ type III or type V according to the Rockwood classification. Arthroscopic surgery was performed with the patient under general anesthesia and interscalene brachial plexus block in the beach-chair position. Reduction of the ACJ was performed manually or using an elevator under control of an imaging intensifier. The ACJ was fixed temporarily with a Kirschner wire. Bone tunnels of the coracoid process and clavicle were made with a cannulated drill. An artificial ligament was pulled out through the bone tunnels and fixed on the upper surface of the clavicle with a staple and interference screw, and on the undersurface of the coracoid process with an Endobutton. The shoulder was immobilized with a shoulder brace for 4 weeks postoperatively, and rehabilitation was started in the first postoperative week. The Japan Shoulder Society Acromioclavicular Joint Function Assessment (JSS-ACJ) score was used for evaluation of clinical outcomes, and plain radiographs were performed after a minimum follow-up period of 5 years postoperatively. RESULTS: The average follow-up period after surgery was 106.3 months (range: 62-128 months). The average postoperative JSS-ACJ score was 97.2 points (range: 92-100). The seven patients who had been playing sports before injury all returned to their pre-injury level. No patients complained of pain or shoulder dysfunction in daily activities, work, or sports. There were no complications such as neurovascular injuries during surgery, infection, or foreign body reaction from the artificial ligament. Radiographs at the final follow-up showed subluxation of the ACJ and non-symptomatic osteoarthritic changes of the ACJ in two patients, respectively. CONCLUSION: ACCLR for acute dislocation of the ACJ is a useful surgical procedure that gives satisfactory clinical and radiologic outcomes on mid- and long-term follow-up. ACCLR can stabilize vertical instability of the ACJ. If instability in the horizontal direction remains, repair or reconstruction of the acromioclavicular ligament should be added to prevent osteoarthritic changes of the ACJ.

Challenges in Treating Acromioclavicular Separations: Current Concepts.

Injuries to the acromioclavicular joint constitute approximately 3.2% of shoulder injuries. Although the overall goal of treatment continues to be return to activity with a pain-free shoulder, the treatment of acromioclavicular joint separations has been fraught with conflict since the earliest reports in both ancient and modern literature. Accurate diagnosis and classification are important to determine the optimal treatment. Nonsurgical therapy remains the mainstay for treatment of low- and most mid-grade injuries, although recent biomechanical and biokinetic data might suggest that patients are more affected than traditionally thought. High-grade injuries often necessitate surgical intervention, although little consensus exists on the timing or technique. New surgical techniques continue to evolve as more biomechanical data emerge and kinematic understanding improves. Challenges associated with management of this injury abound from diagnosis to reconstruction.

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.

Evaluation of effect and safety of arthroscopic surgery with three different operative approaches in patients with terrible triad of the elbow: A comparative study.

BACKGROUND: The terrible triad of the elbow (TTE) is a difficult injury, and the usual TTE consists of posterior dislocation of the elbow, radial head fracture, and coronoid fracture. The target of this retrospective study is to explore the effect, postoperative complications, and prognostic factors in patients with TTE undergoing arthroscopic surgery with three different operative approaches. METHODS: Patients with TTE underwent arthroscopic surgery were treated using lateral, anterior medial, or combined lateral and anterior medial approaches, respectively. In order to analyze the postoperative complications and the effect of arthroscopic surgery for patients with TTE, the function of elbow joint before and after the surgery was evaluated and the flexion-extension of elbow joint and rotation of elbow joint and forearm were measured. RESULTS: The evaluation results obtained from patients underwent 3 different operative approaches revealed that after surgery, patients receiving arthroscopic surgery using combined lateral and anterior medial approach had superior flexion-extension of elbow joint, rotation of elbow joint and forearm, higher Mayo Elbow Performance Score (MEPS) and more cases of Broberg-Morrey grade 0, and lower complication rate, compared with those using lateral or anterior medial approach. A key finding in the study demonstrated that fracture type, operative approach, and postoperative complications were factors related with the effect of arthroscopic surgery for patients with TTE. CONCLUSION: Collectively, the key findings obtained from the present study supported the notion that the effect of arthroscopic surgery in combined lateral and anterior medial approach is much better than in lateral approach or anterior medial approach, and is related with fracture type, operative approach, and postoperative complications.