Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries.

UNLABELLED: Ice hockey is a high contact sport where players are inherently at an increased risk for traumatic and time-loss injury. With its increasing popularity and high incidence of injury, further research is necessary to understand the risks and injuries associated with the sport and to develop performance-based outcome measures to guide return to play. This review, tailored to the practicing sports medicine team physician, focuses on the stepwise identification, treatment, time loss, return to play and subsequent risk of injury for the most common areas of injury: the head, shoulder, hip and knee. Injuries were categorised into upper and lower extremity with an emphasis on glenohumeral and acromioclavicular joint injuries, femoroacetabular impingement, medial collateral ligament tears, and high ankle sprains. With return to play a primary goal for these high-level athletes, recovery in ice hockey becomes a complex issue with efficient protocols tailored to the requirements of the sport vital to the athlete and clinician alike. By reviewing the treatments and sport-specific care, athletes can be better managed with the ultimate goal of returning to their preinjury level of play. LEVEL OF EVIDENCE: Level IV.

Midterm results of combined acromioclavicular and coracoclavicular reconstruction using nylon tape.

PURPOSE: The purpose of this study was to evaluate the radiologic and functional outcomes of an anatomic reconstruction of both acromioclavicular (AC) and coracoclavicular (CC) ligaments in types III to V AC injuries using nylon tape and no metal hardware. METHODS: A prospective case-series study was performed on 17 cases with types III to V AC injuries treated by anatomic reconstruction of the AC ligaments (anterior and superior) and CC ligaments (conoid and trapezoid) using nylon tape and no metal hardware. Clinical assessments, radiologic findings, and visual analog scale, American Shoulder and Elbow Surgeons, and Constant scores were recorded for all patients. After a minimum postoperative period of 2 years, all cases were re-evaluated and rescored. RESULTS: The case-series study comprised 17 cases with types III to V AC injuries. After a mean follow-up period of 28 months (minimum, 24 months), the patients had a significantly improved mean visual analog scale score (from 6.4 to 2.4 points), American Shoulder and Elbow Surgeons score (from 25 to 81.7 points), and Constant score (from 21 to 85 points), with overall 88.2% satisfaction. Radiographic superior displacement showed reduction from 13 to 2 mm whereas posterior displacement showed reduction from 5 to 2 mm, and both were statistically significant (P < .05). The rate of return to the patients' preinjury jobs was 82.4%, and there was 1 case of recurrent subluxation. CONCLUSIONS: Combined anatomic reconstruction of both AC and CC ligaments using nylon tape by the described technique provides overall 88.2% satisfaction, 94% radiologic reduction, and a low complication rate. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Mid to long-term results of open acromioclavicular-joint reconstruction using polydioxansulfate cerclage augmentation.

INTRODUCTION: There is still controversy about the optimal operative treatment of acromioclavicular (AC)-joint dislocations. However, in the current literature, only few studies are available on mid- to long-term results of different stabilization methods. This retrospective study presents the clinical and radiographical results after open reduction and stabilization of AC-joint dislocations using polydioxanesulfate (PDS) cerclage augmentation. METHODS: Fifty patients with a mean age of 35 years were treated with open reduction and PDS cerclage augmentation. Rockwood classification showed 44 type V, 5 type III and 1 type IV AC-joint dislocation. The clinical and radiographic follow-up (Constant Score, DASH Score, subjective shoulder value and stress radiographs of the shoulder girdle) were performed postoperatively at an average of 70 months. RESULTS: Clinical scores were good to excellent with a mean constant score of 91.7 +/- 8.7 points. The mean DASH Score was 5 +/- 8.8 points and the mean subjective shoulder value was 92 +/- 10.7. Radiographically, 80% showed a difference of coracoclavicular distance in comparison to the contralateral side of <5 mm, 14% of 5-10 mm and 6% of >10 mm. Radiographical signs of osteoarthritis were present in 37 and in 6% of all patients also evident during clinical examination. Coracoclavicular calcifications were seen in 68%. Complications were: one superficial wound infection, one extensive coracoclavicular calcification and two complete secondary redislocations. CONCLUSIONS: Treatment of AC-joint dislocation using PDS cerclage augmentation leads to good to excellent clinical results. However, mid- to long-term follow-up reveals a high incidence of radiographic signs of osteoarthritis of the AC-joint. Whether this is due to the surgical technique and could be reduced using other, more anatomical fixation techniques or whether the injury itself leads to these changes, need to be shown.

Minimally invasive coracoclavicular ligament augmentation with a flip button/polydioxanone repair for treatment of total acromioclavicular joint dislocation.

Treatment of complete acromioclavicular joint disruption remains controversial and ranges from rehabilitation to extensive surgical reconstruction. However, high-grade injuries (type IV, V, and VI) are typically treated surgically. Most reconstruction techniques addressing these injuries selectively focus on coracoclavicular ligament augmentation because it has been shown to be the primary stabilizer of the acromioclavicular joint. The conventional coracoclavicular polydioxanone (PDS) loop, which is widely performed, has been detected to have some pivotal disadvantages, including anterior subluxation of the clavicle, extensive preparation of the coracoid, and bony avulsion of the clavicle as a result of rotational clavicle movement. Therefore we present an augmentation technique that reduces these complications by replicating the orientation of the native coracoclavicular ligament complex and providing a minimally invasive subcoracoid and clavicular fixation of a double PDS loop by use of 2 flip buttons, typically used for extracortical anterior cruciate ligament graft fixation. The key step of the procedure includes the anatomic, secure, and stable placement of the double PDS cerclage under the coracoid base transferring a flip button through a coracoid bone tunnel. Our clinical experience shows that the presented technique is easy to perform and has a comparable invasiveness to recently presented arthroscopic techniques.

Acromioclavicular joint disorders.

The acromioclavicular (AC) joint is a highly used, versatile, and complex joint that provides stability and increases function. Acute and chronic dysfunction at the AC joint can have debilitating effects that should be treated appropriately and expediently to preserve function. The historical, physical examination, and radiographic findings are generally very consistent and lead to both diagnosis and well-established treatment protocols. With few exceptions, injuries can be treated nonoperatively with a high degree of success. When indicated, surgical outcomes are also successful but have an overall higher rate of complications. A physician should be well versed in both acute and chronic conditions to ensure the patient has the best opportunity to reclaim function, return to sport, and avoid pain, restriction in range of motion, and need for further surgery.

[Acromio-clavicular dislocations treated by synthetic coraco-clavicular ligamentoplasty]. / Disjonctions acromio-claviculaires traitées par ligamentoplastie synthétique coraco-claviculaire.

PURPOSE OF THE STUDY: The aim of this study was to evaluate results of coraco-clavicular ligamentoplasty using a synthetic material, dacrylene, for the treatment of recent and neglected acromio-clavicular dislocation. MATERIAL AND METHODS: The series initially included 104 patients who underwent surgery from 1981 to 2001. Among these, 75 were reviewed with a mean follow-up of 85 months (72% review rate). A complete set of clinical (Constant score/100 points) and radiographic (coraco-clavicular distance) data was available for 39 patients. Thirty-six answered a questionnaire with measurement of a partial Constant score (65 points). RESULTS: Seventy-seven percent of patients were satisfied or very satisfied and 98% presented good or very good functional outcome as assessed by the partial Constant score. Reduction of the coraco-clavicular distance was satisfactory for 54% of patients evaluated. For the vast majority, insufficient reduction was reducible and had no impact on the functional outcome. The time to treatment (recent or neglected dislocation) had no effect on patient satisfaction or functional outcome. The coraco-clavicular distance was greater for dislocations operated on late (p<0.05). The grade of the injury, the type of assembly used, and use or not of lateral clavicular resection had no effect on clinical or radiological outcomes. Dacrylene was tolerated poorly by 14 patients (18.7%). The functional outcome was very good for all after removal of the ligament. DISCUSSION: Functional results are good with this technique which enables a well sustained stable reduction of recent and neglected dislocations, irrespective of the grade of the lesion or the type of assembly used. Reducing the mechanical stress on the ligament and prudent rehabilitation exercises should be helpful in preventing intolerance reactions.

[Operating treatment results of acromioclavicular (joint) abarticulations in materials of the Traumatic and Orthopedic Surgery unit and Rehabilitation Unit in Dabrowa Tarnowska]. / Wyniki leczenia operacyjnego zwichniec stawu barkowo-obojczykowego w materiale Oddzialu Chirurgii Urazowo-Ortopedycznej i Rehabilitacji w Dabrowie Tarnowskiej.

The work presents results of operative treatment of acromioclavicular (joint) abarticulations using two different materials during syndesmoplasty of the coracoclavicular ligament, the steel loop of wire and the coal fibre (fabrics). Examining the patients, all the advantages and disadvantages of the treatment have been pointed out. In the reconstruction of coracoclavicular ligament, better results were obtained when using the steel loop.

Stress fracture of the clavicle leading to nonunion secondary to coracoclavicular reconstruction with Dacron.

We have reported the case of a nonunion of a clavicle fracture in which the Dacron had eroded the bone and acted as a stress riser contributing to the fracture. The Dacron then became interposed in the fracture site preventing union.

Treatment of acromioclavicular separations. A retrospective study.

A retrospective study of 134 patients with Types I, II, and III acromioclavicular separations was carried out. The average followup was 6.3 years, with the longest being 19 years, and the shortest being 1 year. The mechanism of injury was a direct blow in 92% of the patients. The average age of the patients was 30.1 years, with a range from 13 to 68 years. All patients were evaluated using a standard rating system for the shoulder and humerus, the total for perfect recovery being 100. Twenty-four patients with Type I separations were immobilized 19.5 days, with a disability period of 6 weeks, and rated 94 points. Twenty-five patients with Type II separations were immobilized 27 days for the conservative groups, had a disability period of 6 weeks, and rated 90 points. Eighty-five patients with Type III acromioclavicular separations were followed. Seven patients had conservative treatment, were immobilized an average of 22 days, with a disability period of 13 weeks, and rated 82. Of those patients who underwent surgical repair, excluding Dacron graft substitution, the immobilization period was 6 weeks, with a disability period of 12 weeks, and a rating of 80. Fifty-eight patients underwent repair with double velour Dacron prosthetic substitution for the coracoclavicular ligaments, combined with distal clavicular resection in all but two patients. The average immobilization period was 1 week, with the average disability period being 3 weeks. The average rating was 96, with 24 patients rating 100. The major cause for a rating less than 100 was light to moderate pain that persisted in a few cases, which was only occasional and associated with a particular activity. One infection occurred requiring graft removal 5 months after surgery. Calcification in the area of the coracoclavicular ligaments did not affect the final rating and recurrence of deformity was not noted.

Acromioclavicular reconstruction augmented with polydioxanonsulphate bands. Surgical technique and results.

During a 5.5-year period, we treated 64 patients with acute acromioclavicular separations by surgical reconstruction. According to the classification of Rockwood and Matsen, 54 patients had type III lesions, 1 patient had a type IV lesion, and 9 patients had type V lesions. Both the coracoclavicular ligaments and the ligaments of the acromioclavicular joint were reconstructed. An additional ligamentous augmentation was performed using completely resorbable 5- and 10-mm polydioxanonsulphate bands. Forty-five patients (70%) were re-examined at 2 to 7.5 years after surgery (mean, 32 months). The results were good or excellent in 40 cases (89%). Forty-one patients (92%) achieved a range of motion with an abduction deficit of less than 20 degrees. Calcifications in the area of the coracoclavicular or acromioclavicular ligaments did not affect the final range of motion. Complications consisted of one subcutaneous infection, one deep infection, and one failure of the reconstruction. Augmenting the reconstruction with polydioxanonsulphate bands allowed an early functional postoperative treatment. With this procedure, patients do not require removal of an implant, and complications from breakage or migration of metal implants are avoided.

Acromioclavicular separation. Reconstruction using synthetic loop augmentation.

A total of 110 patients with a diagnosis of acromioclavicular joint separation were seen at our clinic between 1986 and 1991. Of these, 14 patients (12.7%) with grade III, IV, or V injuries required surgical reconstruction and were examined 2 years after surgery. All 14 patients underwent acromioclavicular reconstruction using a synthetic loop passed through drill holes in the base of the coracoid and the anterior third of the clavicle. When the loop is tightened, the clavicle is reduced anatomically without the anterior subluxation caused by simple clavicular cerclage. At an average followup of 44.2 months, patients were evaluated using the University of California, Los Angeles, rating scale. Twelve of the 14 had good or excellent results and returned to normal sport and work activities at 6 months. Of the two initial poor results, one required revision 1 month post-operatively because the patient was noncompliant, and the other required manipulation under anesthesia 3 months after surgery. The results in these two patients at 2 years were good and excellent, respectively. We concluded that, when medically indicated, fixation of the clavicle to the coracoid using this technique yields satisfactory results in an athletic population.

Shoulder injuries in the athlete.

Most shoulder injuries in the athlete can be managed nonoperatively; prior to any management, however, they require careful evaluation for accurate diagnosis. Once the diagnosis has been made, few of these injuries will actually require surgery and most will obtain an excellent result with full return to function. Several specific shoulder injuries are discussed and their treatment is outlined.

[Results of treatment after different surgical procedures for management of acromioclavicular joint dislocation]. / Behandlungsergebnisse nach unterschiedlichen Operationsverfahren zur Versorgung einer Schultereckgelenksprengung.

Sixty-four patients underwent surgery for acromioclavicular (AC) disruption, Tossy type III, at the Department of Surgery, University of Heidelberg, between January 1983 and May 1990. Surgery consisted of a suture of the AC and coracoclavicular ligaments. Fixation of the joint was achieved with three different techniques: tension band wire with two Kirschner wires, special hook-plate (Wolter), double tension band fixation using polydioxanon (PDS) cordula. The early postoperative complication rate was higher following tension band wires (42.9%) and hook plate (58.3%) than after tension band PDS cordula (16.7%). The patients were re-examined after an average of 35.3 months. An instability of the AC joint was found in 31.8% of patients with tension band wire, 50.0% of patients with Wolter plate, and 23.8% of patients with tension band PDS cordula. The comparison of these results with those after conservative treatment, as reported in the literature, emphasizes the need for limiting surgery to young adults and athletes. The long term results of AC joint fixation are better using PDS cordula than tension band wire or hook plate. PDS cordula has the additional advantages, that dislocation and fracture of metal implants do not occur, and metal removal is avoided. Therefore, tension PDS cordula is associated with a marked reduction of the overall hospitalization period. Further improvements of results of AC joint fixation can be expected using the described technique of double tension band PDS cordula.

Reconstruction of complete acromioclavicular separations (Tossy III) using PDS-banding as augmentation: experience in 64 cases.

Sixty-four patients with an acute type Tossy III acromioclavicular separation were treated surgically. Both the coracoclavicular ligaments and the ligaments of the acromioclavicular joint were reconstructed. An additional ligamenteous augmentation was performed, using completely resorbable 5 and 10 mm PDS bands. Thirty-nine patients (61%) were reexamined (follow-up time 2-45 months, mean 26 months). Results were good to excellent in 77% of cases. In 91% of patients, a range of motion with an abduction deficit of less than 20 degrees was obtained. Calcifications in the area of the coracoclavicular or acromioclavicular ligaments did not affect the final range of motion. Complications consisted of a subcutaneous infection in one case, a deep infection in another patient and one reluxation. PDS banding enables an early functional postoperative treatment. Implant removal is not required. Complications as breakage or migration of metal implants are avoided.

Surgical treatment of acute type V acromioclavicular injuries. A prospective study.

In a prospective study, 28 consecutive patients with an acute Type V acromioclavicular sprain were treated with a coraco-clavicular repair using a double velour Dacron graft. All patients were reviewed after a mean follow-up period of 5.1 years (range: 1 to 9 years). At follow-up, 20 patients (71.4%) showed good or excellent results, according to the Imatani evaluation system, and 8 patients (28.6%) demonstrated a fair or poor result according to the same system. Loss of reduction was encountered in 11 shoulders (40%), despite an initial anatomical reduction. No correlation was seen between the overall scores at follow-up and the degree of residual dislocation, between the overall scores and the presence of coraco-clavicular calcifications or ossifications, between the overall scores and the development of posttraumatic arthritic changes, or between the overall scores and the presence of osteolysis of the distal clavicle.

[Distal clavicular fracture and dislocation of acromino-clavicular jiont treated with biopoly ligament].

OBJECTIVE: To probe into distal clavicular fracture and acromino-clavicular joint dislocation treatment. METHODS: 11 cases of distal clavicular fracture and 20 cases of acromino-clavicular joint dislocation were treated with biopoly ligament in recent 2 years. The follow-up period lasted from 3 to 24 months with an average of 16.7 months. RESULTS: Of 29 follow-up cases, 21 were excellent and 8 satisfactory. There was no redisplacement or refracture. CONCLUSION: Biopoly ligament is believed to be a good and safe material for this fracture or dislocation. This method is simple without needing a second operation for removal of implant.

[Treatment of acromioclavicular dislocation with resorbable fixation material]. / Osetrení AC luxací resorbovatelným fixacním materiálem.

The demand of biological treatment of acromioclavicular luxations is met by the use of Polydioxanon strips (PDS). Artificial damage of the joint does not occur and the bond is elastic. Thus removal of metal which ensures rigid fixation of the joint is eliminated. This makes it possible to achieve within a short period a normal range of movements.

[Results following the surgical treatment of acromioclavicular joint dislocations. A comparison of direct trans- and extra-articular fixation]. / Ergebnisse nach operativer Behandlung von Akromioklavikulargelenkssprengungen. Ein Vergleich von direkter trans- und extraartikulärer Fixation.

During the years 1985-1988, a total of 41 patients were treated for acromioclavicular dislocations. 25 (61%) were followed postoperatively for an average of 21 months. Two different methods of direct fixation of the AC-joint were compared: in 13 patients the transarticular fixation with two Kirschner wires and a 7.5 mm biodegradable Polydioxanon band (group I); in 12 patients an extraarticular fixation with PDS-band alone (group II). In both groups the ruptured ligament were sutured. In the first group physiotherapy was instituted immediately with limitation in abduction range to ninety degrees. After six weeks the Kirschner wires were removed under local anaesthesia and physiotherapy progressed to full range of motion. The shoulders of the second group patients were immobilized for 4 weeks. All of the patients were evaluated at follow-up on a subjective (pain, stiffness), objective (strength, range of motion, stability of the AC-joint) and roentgenographic (degree of displacement, posttraumatic arthritis, calcifications around the injured ligaments) basis. In both groups we saw good and satisfying results in more than 90%. A significant difference exists only as far as rehabilitation time is concerned. It was shorter in group I. In spite of the complications we observed with the metallic implants, which didn't have any negative influence on the results, we prefer the transarticular fixation method, because an immobilization postoperatively is not necessary and the time of rehabilitation is shortened.

[Surgical management of complete acromioclavicular joint dislocation (Tossy III) with PDS cord cerclage]. / Operative Versorgung der kompletten Schultereckgelenkluxation (Tossy III) mit PDS-Kordel.

29 patients out of 33 with complete acromioclavicular dislocation treated with sewing of ligaments and stabilized with a PDS-cord cerclage could be examined. The criteria of examination were subjective complaints while lifting weight, limited range of motion in the injured shoulder and radiological results after stress with 8 kp. The examination didn't show any relationship between the 3 parameters. 4 patients with poor function had partly no, partly little complaints and if any only little AC-dislocation. On the other hand 4 patients out of 6 with remaining AC-subluxation had no complaints and in no case there was a reduced range of motion greater than 10 degrees. Three patients got postoperative infection of soft tissue or bone, probably caused by incompatibility with PDS-cord, which led to a fair or poor outcome. Instead of this there can be obtained excellent and good results in 75-85% of the cases with this simple method without inserting stabilizing metals trans- or extraarticular.