Management of type III acromioclavicular joint dislocation: A Delphi consensus survey by Shoulder & Elbow Society, India (SESI).

PURPOSE: The study aimed to report the results of the Delphi survey conducted by the Shoulder, Elbow Society India (SESI), to achieve consensus on ambiguous topics in managing type III acromioclavicular joint (ACJ) dislocations. METHODS: This study was based on responses from the Shoulder Elbow Society India (SESI) panel of peer-selected twenty senior surgeons practicing shoulder orthopedics. They participated in two rounds of the survey to obtain consensus on several topics pertaining to the management of type III ACJ dislocations. Consensus was achieved when at least 70 % of the panel members selected at least a 4-point on a 5-point Likert scale. RESULTS: Our Delphi survey reached a consensus on seven topics of ambiguity. An anteroposterior and axillary view of the shoulder without any traction or weight in hand is sufficient in the setting of a suspected type III ACJ dislocation. Magnetic resonance imaging (MRI) is not routinely indicated in type III ACJ dislocation. Either cross-arm adduction X-rays or clinical examination may be used to distinguish between ISAKOS (International Society of Arthroscopy, Knee surgery and Orthopaedics Sports medicine) IIIA and B classification of ACJ to identify stable and unstable injuries. Conservative treatment can be offered to patients who have stable injuries and who are not high-demand individuals in acute type III ACJ dislocations. In conservative management of type III ACJ dislocation, a two-week sling suffices. Jones strapping has no clear advantage over a shoulder sling. Coracoclavicular reconstruction with an autograft is an acceptable way to treat symptomatic, chronic grade III ACJ dislocation. CONCLUSION: The survey helped achieve consensus on several controversial issues related to type III ACJ dislocations. However, there remains ambiguity on the definition of chronicity of such dislocations, the necessity of bilateral Zanca views, and the duration of conservative trial before switching to a surgical line of management.

[Current treatment concepts of the lateral clavicle and the acromioclavicular joint]. / Aktuelle Versorgungskonzepte der lateralen Klavikula und des Akromioklavikulargelenks.

Injurie to the lateral clavicle and acromioclavicular joint (ACJ) are frequent events which are relevant to everyday life and particularly affect active adults at the age of 20-40 years. The Rockwood classification has been established for the classification of ACJ injuries. Lateral clavicle fractures are classified according to the Neer classification or the Jäger and Breitner classification. A newly established classification is the Cho classification. Depending on the injury pattern and in particular the presence of instability, various conservative and surgical care strategies are used. This article provides an overview of the various treatment concepts.

Outcomes following fixation of distal clavicle fractures utilizing arthroscopically assisted coracoclavicular ligament stabilization with a suspensory endobutton and cerclage tape.

Background: Distal one-third clavicle fractures are frequently unstable and often require surgical fixation due to high rates of nonunion. Many common methods of fixation have high rates of union but are associated with hardware discomfort and need for secondary surgery. The purpose of this study was to evaluate the outcomes of a fixation technique involving arthroscopically assisted open reduction internal fixation of unstable distal clavicle fractures via a coracoclavicular (CC) suspensory endobutton and cerclage tape. Methods: This was a retrospective case series evaluating patients who underwent fixation of unstable distal clavicle fractures via arthroscopically assisted CC stabilization by a single fellowship-trained shoulder and elbow surgeon between 2020 and 2022. Demographic and injury-related data were collected via chart review. Preoperative and postoperative radiographs were reviewed to evaluate for signs of radiographic union. Primary outcome measures included fracture union, complications, and need for additional procedures. Patients were also contacted via telephone to obtain American Shoulder and Elbow Surgeons scores. Results: Six patients were eligible for inclusion in this study with a mean age of 52.8 ± 14.0 and a mean follow-up of 2.0 years (range 1.6-2.7 years). Mean American Shoulder and Elbow Surgeons scores were 86.2 ± 21.8 (range 52-100). There were no postoperative complications, signs of symptomatic hardware, or need for secondary surgery at the final follow-up among this cohort of patients. All patients had achieved and maintained full radiographic union at a mean radiographic follow-up of 5.5 months (range 2.0-12.9 months). Conclusion: Arthroscopically assisted CC stabilization of distal clavicle fractures demonstrated high union rates while limiting complications or need for secondary hardware removal. Further analysis on a larger scale is recommended to determine long-term outcomes and direct comparison to other surgical techniques.

Comparative clinical outcomes and radiological images of clavicle hook plate versus Scorpion Plate® for unstable distal clavicle fractures.

BACKGROUND: Although various surgical methods are available for unstable distal clavicle fractures, consensus remains lacking on the optimal technique. Therefore, the present retrospective study aimed to compare the clavicle hook plate and Scorpion Plate® in terms of clinical outcomes and radiological findings for unstable distal clavicle fractures. METHODS: Fifty-seven patients with unstable distal clavicle fractures who underwent treatment using a clavicle hook plate (Group H; 28 patients) or Scorpion Plate® (Group S; 29 patients) were included in the present study. No patients received additional augmentation and all were followed-up for >1 year (mean follow-up, 28 months). Clinical outcomes were operation time, bleeding volume, complications, range of motion (ROM) at 6 months after surgery and final follow-up, and clinical scores (Constant-Murley score and University of California, Los Angeles (UCLA) shoulder score). Radiological outcomes assessed were coracoclavicular distance (CCD), difference in CCD between affected and non-affected sides (ΔCCD), and acromioclavicular subluxation ratio (%ACS) from plain X-rays. The χ2 test and Mann-Whitney U test were used to compare each outcome. RESULTS: Complications were seen in 3 shoulders (10.7%) in Group H. ROM was significantly worse in Group H at 6 months postoperatively, but no significant differences between groups were evident at final follow-up. Moreover, no significant differences in clinical outcomes were seen between groups. In terms of radiological results, Group H showed greater improvement in CCD and ΔCCD than Group S. Further, %ACS was significantly worse in Group S. CONCLUSIONS: The clavicle hook plate allows reconstruction of a more anatomical position than the Scorpion Plate®, but carries a greater risk of complications. Conversely, the Scorpion Plate® has a low risk of complications, but acromioclavicular subluxation remains. However, no significant differences in ROM or clinical outcomes were apparent at final follow-up.

[Single mini-incision combined with honeycomb titanium plate in treatment of acute acromioclavicular joint dislocation].

OBJECTIVE: To explore clinical effect of single small incision with honeycomb titanium plate in treating acute acromioclavicular dislocation. METHODS: The clinical data of 40 patients with acute acromioclavicular dislocation admitted from December 2019 to December 2021 were retrospectively analyzed and divided into two groups according to different surgical methods. Among them, 20 patients were fixed with single small incision with honeycomb titanium plate (titanium plate group), including 11 males and 9 females, aged from 23 to 65 years old with an average of (47.40±12.58) years old;12 patients on the left side, 8 patients on the right side;11 patients with type Ⅲ, 3 patients with type Ⅳ, and 6 patients with type Ⅴ according to Rockwood classification. Twenty patients were fixed with clavicular hook plate (clavicular hook group), including 8 males and 12 females, aged from 24 to 65 years old with an average of (48.40±12.08) years old;12 patients on the left side, 8 patients on the right side;10 patients with type Ⅲ, 2 patients with type Ⅳ, and 8 patients with type Ⅴ according to Rockwood classification. Operative time, incision length, intraoperative blood loss, hospital stay, visual analogue scale (VAS) and Constant-Murley score of shoulder joint function were compared between two groups. Anteroposterior radiographs of the affected shoulder joint were recorded before, immediately and 6 months after surgery, and the coracoclavicular distance was measured and compared. RESULTS: Both groups of patients were successfully completed operation without serious complications. All patients were followed up for 6 to 15 months with an average of (11.9±4.8) months. There were no incisional infection, internal plant fracture or failure, bone tunnel fracture and other complications occurred. The incision length of titanium plate group (35.90±3.14) mm was significantly shorter than that of clavicular hook group (49.30±3.79) mm (P<0.05). There were no significant difference in operative time, intraoperative blood loss and hospital stay between two groups (P>0.05). At 1 and 3 months after operation, VAS of titanium plate group was lower than that of clavicular hook group (P<0.05). Connstant-Murley scores in titanium plate group at 1, 3 and 6 months after operation were (86.80±1.36), (91.60±2.32) and (94.90±2.22), respectively;and in clavicular hook group were (78.45±5.47), (85.55±2.01) and (90.25±1.92), which were higher than that of clavicular hook group (P<0.05). There was no significant difference in coracoclavicular distance between two groups immediately and 6 months after operation(P>0.05). CONCLUSION: For the treatment of acute acromioclavicular joint dislocation, single small incision combined with honeycomb titanium plate have advantages of shorter incision, fast recovery of shoulder joint function without the second operation, and has good satisfaction of patient.

Early to Mid-term Results of Coracoclavicular Ligament Reconstruction Using the Infinity-Lock Button System in the Management of Traumatic Acromioclavicular Joint Dislocations and Lateral End of Clavicle Fractures.

Background The management of distal clavicle injuries with disruption of the coracoclavicular ligaments (CCLs) is challenging. The aim of this study was to assess the functional results of reconstructing the CCLs with the Infinity-Lock Button System using validated outcome measures, patient satisfaction scores, return to pre-injury activity, and complications. Methods A total of 28 cases of CCL disruption were assessed over a seven-year period, which included 14 lateral end-of-clavicle fractures and 14 acromioclavicular joint (ACJ) dislocations. All patients underwent stabilisation of the CCLs using the Infinity-Lock Button System. Patients were assessed preoperatively and postoperatively using validated outcome measures such as visual analogue scale (VAS), Oxford Shoulder Score (OSS), Quick Disabilities of Arm, Shoulder & Hand (Q-DASH) scores, return to pre-injury level of activities, patient satisfaction scores, and complications were reviewed. Results The mean age of patients was 36.7 years (18-74 years). The mean follow-up was 38.6 months (8-68 months). The mean time to surgery was 75.8 days (3-619 days). There was a statistically significant improvement in postoperative VAS, OSS, and Q-DASH scores compared to the preoperative (p-value <0.001). Out of the 28 participants, 23 (82.1%) returned to pre-injury level of activities, 25 (89.7%) reported 'good' or 'excellent' outcomes following the intervention, and none of the patients reported functional instability postoperatively. None of the patients required revision surgery or implant removal. Conclusion CCL reconstruction is vital in the management of clavicular injuries. This study demonstrates the safe use of the Infinity-Lock Button System in these injuries with statistically significant improvement in early patient-reported outcome measures, return to pre-injury level of activities, and subjective patient satisfaction.

Medial placement of trapezoid tunnel leads to higher reduction loss in acute acromioclavicular joint dislocation treated with anatomic coracoclavicular fixation.

Aim: To analyze the association between clavicular tunnel positioning and postoperative reduction loss in patients with acute acromioclavicular (AC) joint dislocation treated with anatomic coracoclavicular (CC) fixation using double clavicular tunnels. Methods: A retrospective review of patients with AC joint dislocation, treated with anatomic CC fixation using double clavicular tunnels, was conducted. Patients with pre-operative, immediate post-operative, and final follow-up Zanca-view X-rays were included. On each X-ray, the obtained measures included: distance from lateral border of clavicle to trapezoid and conoid tunnels, distance between tunnels, clavicle length, and CC distance of affected and un-affected sides. Loss of reduction was calculated as CC distance difference between immediate and final post-operative X-rays. Association between reduction loss and tunnel positioning was analyzed. Results: Conoid, trapezoid and tunnel ratios were 24% ± 4, 15% ± 3, and 9% ± 2, respectively. Significant reduction loss was seen in 21(45.7%) patients. Significantly higher probabilities of reduction loss were associated with trapezoid tunnels placed medial to 24 mm (30.8% vs 65.0%, OR 4.2 (IC95%: 1.2-14.4), p: 0.024) or 15% of the clavicle length (32.1% vs 66.7%, OR 4.2 (IC 95%: 1.2-14.9), p: 0.025). Conclusions: Trapezoid tunnels placed medial to 24 mm or 15% medial to clavicle length could lead to higher probabilities of significant reduction loss. These findings support the importance of clavicular tunnels' proper placement for decreasing significant reduction loss.

Biomechanical evaluation of fixation of the coracoclavicular stand-alone cow-hitch suture reconstruction in comparison to two established techniques for highly unstable distal clavicle fractures (Neer type V).

Background: Treatment of displaced distal clavicle fractures with bony avulsion of the coracoclavicular (CC) ligaments often warrants surgical fixation, yet a gold standard surgical technique is to be defined. The purpose of this study was to compare the biomechanical fixation strength of a new fixation technique, the CC stand-alone cow-hitch suture reconstruction, and to compare this technique with a clavicle hook plate and a lateral locking plate with CC suture reconstruction. Methods: Simulated Neer type V distal clavicle fractures of the clavicle were created in 18 cadaveric shoulders, which were matched by age and gender in 3 groups: (1) clavicle hook plate (group HP), (2) lateral locking plate fixation with CC suture reconstruction (group LPCC), and (3) CC stand-alone suture reconstruction using the cow-hitch technique (group CH). After preconditioning with 25 N for 10 cycles, the specimens were cycled in the coronal plane for 500 cycles from 10N to 70N. Displacement and ultimate load to failure were documented and analyzed with the data acquisition system. Results: There was a significant difference in the fracture displacement during cyclic loading between the LPCC group and the HP group (0.6 vs. 1.7 mm; P = .02) and between the CH and HP groups (0.5 vs. 1.7 mm; P = .004). Fracture displacement was not different between the LPCC and the CH groups (P = .544). The CH group and the LPCC group showed a significantly higher stiffness compared to the HP group (P < .001 and P = .003, respectively). The CH group showed a significantly higher ultimate load to failure compared with the HP group (429 vs. 172 N; P = .005) and showed a tendency toward higher ultimate load to failure when compared with the LPCC group (429 vs. 258 N; P = .071). Conclusion: The CC stand-alone cow-hitch suture reconstruction and the locking plate with CC reconstruction showed higher fixation strength compared with the hook plate for simulated Neer type V distal clavicle fractures. There was a tendency of higher ultimate load to failure with the cow-hitch technique compared with the lateral locking plate with CC suture reconstruction, and given the potential advantages of less soft tissue stripping, metal-free fixation, low costs, and simple surgical technique, clinical application of the all-suture CC reconstruction using the cow-hitch for Neer type V distal clavicle fractures appears warranted.

Reconstruction of Coracoclavicular Ligaments with Semitendinosus Autograft and Temporary Kirschner Wires is a good option for Chronic Acromioclavicular Joint Instability.

Introduction: This study reports the results of surgical anatomic reconstruction of torn coracoclavicular ligaments with an autogenous semitendinosus graft and temporary Kirschner wires (K-wires) in chronic acromioclavicular (AC) joint dislocations. Materials and methods: Nineteen shoulders underwent surgical anatomic reconstruction of torn coracoclavicular (CC) ligaments with an autogenous semitendinosus tendon graft and temporary K-wires for Rockwood grade III, IV and V chronic AC joint dislocations. Pre-operative data included patients' demographic characteristics, injury characteristics and surgical histories. The primary outcome measures were the University of California Los Angeles (UCLA) shoulder rating scale and visual analogue pain scoring (VAS), and the complications were noted for each patient. Results: Surgical anatomic reconstruction of torn CC ligaments was performed in 19 patients with a mean age of 41.6±16 years (range 21-72 years). All of the patients were satisfied and felt better after CC ligament reconstruction. The average UCLA shoulder rating scale score was good/excellent: 29.4 (range 23-34) out of 35 points. The average pre-operative VAS score was 7.7 points out of 10 and improved to 1.1 points post-operatively (p<0.05). None of the patients experienced failure during the follow-up. One patient had a mild subluxation, but the patient was satisfied with the result. Conclusions: This technique is simple, reliable, and biologic without major complications. It is also a cost-effective procedure since it can be performed with Kirschner wires and autogenous grafts. It has a major advantage of leaving no implants inside the joint, which can lead to hardware complications, and it can be performed in basic operating room settings.

Efficacy of allogeneic tendon material coracoclavicular ligament reconstruction combined with Kirschner wire and titanium alloy hook plate material fixation in the treatment of acromioclavicular joint dislocation.

Objective: To compare the effects of allogeneic tendon coracoclavicular ligament reconstruction combined with Kirschner wire fixation and clavicular hook plate fixation on early postoperative pain, postoperative shoulder joint function score and shoulder joint mobility in patients with acromioclavicular joint dislocation. Methods: From January 2020 to January 2023, 43 patients with acromioclavicular joint dislocation admitted to Xi 'an Honghui Hospital were included. Among them, 24 patients were treated with the clavicular hook plate technique (Hook Plate,HP) group, and 19 patients were treated with allogeneic tendon coracoclavicular ligament reconstruction combined with the Kirschner wire technique (Allogeneic Tendon, AT) group. The Constant-Murley score of shoulder joint function 6 months after operation, postoperative shoulder joint activity, preoperative and postoperative pain, operation time, intraoperative blood loss and complications were compared between the two groups. Results: All 43 patients were followed up for an average of 9.7 (9-12) months. The intraoperative blood loss in the allogeneic tendon group was less than in the hook plate group. The Constant-Murley shoulder function score was higher than that in the hook plate group 6 months after the operation. The abduction and lifting activity was greater than that in the hook plate group. The visual analogue scale scores at 3 days and 14 days after operation were lower than those in the hook plate group. The difference was statistically significant (p < 0.001). There was 1 case (5.3%) of exudation around the Kirschner needle track in the allogeneic tendon reconstruction group, and 5 cases (20.8%) of complications in the hook plate group, including 1 case of internal fixation stimulation, 2 cases of acromion impingement syndrome, 1 case of acromioclavicular joint osteoarthritis, and 1 case of shoulder joint stiffness. The complication rate of the allogeneic tendon group was lower than that of the hook plate group. Conclusion: The clinical efficacy of allogeneic tendon coracoclavicular ligament reconstruction combined with Kirschner wire fixation in treating acromioclavicular joint dislocation (Rockwood type III-V) is better than hook plate internal fixation. The patients have less early postoperative pain and better recovery of shoulder joint function and shoulder joint mobility.

An In Vitro Study Demonstrating the Significance of Acromioclavicular Ligament Repair in Restoring Horizontal and Rotational Acromioclavicular Joint Stability.

BACKGROUND: The principle of joint reconstruction surgery is to try to recreate the native joint biomechanics and stability. With respect to acromioclavicular joint (ACJ) surgery, much focus to date has been on restoring the superoinferior stability. There is concern that persistent horizontal instability following ACJ reconstruction could lead to poorer patient outcomes; therefore, we evaluated whether acromioclavicular (AC) ligament repair offers improved horizontal stability in conjunction with ACJ reconstruction. METHODS: A whole-body human cadaver was used. The ACJ was exposed and subjected to a constant 70N load on the lateral end of the clavicle to test the anteroposterior (AP), superoinferior (SI), and horizontal pivot angle (HPA) around the ACJ. The AC and coracoclavicular (CC) ligaments were subsequently divided, and the above three parameters were re-tested. Ligament augmentation and reconstruction system (Corin Group, Cirencester, UK), LockDown (LockDown Medical Limited, Redditch, UK), Endobutton (Smith and Nephew Inc., London, UK), and Neoligament implant (Xiros Ltd., Leeds, UK) were used to reconstruct the CC ligaments and tested with and without AC repair. RESULTS: The native ACJ allowed an average 2.48 mm AP and 3.88 mm SI translation with a 27° HPA. All synthetic implants significantly improved the vertical stability of the ACJ but allowed up to a four-fold increase in AP translation. Coupled with ACJ repair, all the reconstructions were far superior, especially in restoring horizontal stability. CONCLUSION: The implants varied in their approach to fixation and concentrated primarily on the reconstruction of CC ligaments. Our study was able to demonstrate that AC repair significantly improves the stability of the construct and significantly reduces vertical and horizontal instability.

Current Concepts in Management of Acromioclavicular Joint Injury.

Background: The management of acromioclavicular joint injuries requires a thorough understanding of the anatomy and biomechanics of the joint, as well as knowledge of the pertinent physical exam findings and classification to determine an appropriate treatment approach, whether operative or nonoperative. In this article, we present a narrative review of the current state of understanding surrounding these issues. Although there are a large number of options for operative intervention, we additionally present our experience with anatomic coracoclavicular ligament reconstruction (ACCR) with imbrication of the deltoid fascia. Methods: A retrospective review of prospectively collected data on a total of 45 patients who had undergone ACCR between 2003 and 2016 were collected. Results: We found that improvements were seen in American Shoulder and Elbow Surgeons Score (ASES) (53 ± 19 to 81 ± 23), Simple Shoulder Test (SST) (6 ± 3 to 12 ± 13), Constant-Murley (CM) (60 ± 18 to 92 ± 8), and Rowe (67 ± 14 to 89 ± 11) and the mean post-operative SANE score was 86 ± 17. Conclusions: ACCR has the advantage of addressing both horizontal and vertical stability with good outcomes.

Arthroscopically Assisted Coracoclavicular (CC) Stabilization Using a Suture Button Device for Lateral Clavicle Fractures with CC Ligament Injury.

Background: Lateral clavicle fractures represent approximately 10-15% of all clavicle fractures. However, controversy exists regarding the optimal surgical treatment because of instability associated with the coracoclavicular (CC) ligament injury and a small lateral fragment. The purpose of this study was to evaluate the radiological and clinical outcomes of arthroscopically assisted CC stabilization using a suture button device for lateral clavicle fractures accompanied by CC ligament injury. Methods: A retrospective observational study involved six patients with modified Neer type IIB fractures, which were treated with the technique and followed for 12 months. Postoperative range of motion (ROM) and X-rays were evaluated every 3 months. Shoulder functional scores (University of California Los Angeles score, Japanese Orthopedics Association score) and visual analog scale (VAS) scores for pain (at rest, at night, and during motion) and for satisfaction were analyzed 12 months after surgery. Results: Early phase ROM recovery and excellent outcomes were achieved. All patients achieved bone union. Slight superior clavicle displacement and bone hole dilation occurred with no critical complications. Conclusions: Arthroscopically assisted CC stabilization with a suture button device for unstable lateral clavicle fractures can produce satisfactory radiological and clinical results.

Coracoclavicular and acromioclavicular ligament reconstruction with a double-bundle semitendinosus autograft and cortical buttons for chronic acromioclavicular joint dislocations: clinical and imaging outcomes.

BACKGROUND: There are few clinical and radiographic studies of coracoclavicular (CC) ligament reconstruction in chronic acromioclavicular (AC) joint dislocation. Additionally, reported AC joint reduction rates vary. HYPOTHESIS: Arthroscopically assisted double-bundle semitendinosus tendon autografts with CC and AC ligament reconstruction for AC joint reconstruction provide AC joint stability and improved function at the final visit. METHODS: In this retrospective study of prospectively collected data, 21 patients surgically treated for chronic AC joint dislocation (Rockwood III-V) were assessed clinically and radiographically preoperatively, and at day 1, 3 months, 12 months, and at a final visit (>24 months) postoperatively. Clinical assessments included Constant and American Shoulder and Elbow Surgeons scores. The CC vertical distance (CCD) on the affected and unaffected sides [CCD ratio (%)] on the anterosuperior view were measured. AC joint vertical reduction loss was defined as an increase in the CCD ratio of >25%. Horizontal AC joint instability was evaluated on axillary views. Pearsons' correlation coefficients were generated to examine the relationships among postoperative clinical scores, CCD ratio, interval from injury to surgery, and age at the time of surgery. RESULTS: Twenty-one shoulders in 21 patients (mean age, 40.0 years at the time of surgery; 16 men, 5 women) were evaluated with a mean 31.7-month follow-up period. The mean Constant scores, American Shoulder and Elbow Surgeons scores, and CCD ratios significantly improved from preoperatively to the final visit (57.4 ± 10.1, 49.1 ± 12.1, 101.6 ± 64.1 preoperatively; 89.6 ± 5.3, 96.5 ± 4.2, 9.9 ± 34.5 at the final visit, respectively [P < .001 for all]). Vertical AC and horizontal AC joint instability were observed in 4 shoulders (19.0%) and in 1 shoulder (4.8%), respectively. However, there was no significant correlation between the increase in CCD and clinical scores at the final visit (Constant score; r = 0.179, P = .438: American Shoulder and Elbow Surgeons score; r = -0.260, P = .256) or the interval from injury to surgery (r = 0.099, P = .669) or age at the time of surgery (r = 0.019, P = .935). No clinical complications were associated with clinical symptoms. CONCLUSIONS: Patients who underwent the index procedure achieved significant improvement in shoulder function without complications related clinical symptom after a mean follow-up interval of 31.7 months. In contrast, the rates of total ACJ instability in the vertical and horizontal planes were unsatisfactory but compatible with those in previous studies.

Long-Term Functional Outcomes and Athletic Ability in Shoulder Sports After Anatomic Coracoclavicular Ligament Reconstruction for Chronic Type 3 and 5 Acromioclavicular Joint Injuries.

Background: Promising short- and midterm outcomes have been seen after anatomic coracoclavicular ligament reconstruction (ACCR) for chronic acromioclavicular joint (ACJ) injuries. Purpose/Hypothesis: To evaluate long-term outcomes and shoulder-related athletic ability in patients after ACCR for chronic type 3 and 5 ACJ injuries. It was hypothesized that these patients would maintain significant functional improvement and sufficient shoulder-sport ability at a long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: Included were 19 patients (mean age, 45.9 ± 11.2 years) who underwent ACCR for type 3 or 5 ACJ injuries between January 2003 and August 2014. Functional outcome measures included the American Shoulder and Elbow Surgeons (ASES), Rowe, Constant-Murley, Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores as well as the visual analog scale (VAS) for pain, which were collected preoperatively and at the final follow-up. Postoperative shoulder-dependent athletic ability was assessed using the Athletic Shoulder Outcome Scoring System (ASOSS). Shoulder activity level was evaluated using the Shoulder Activity Scale (SAS), while the Subjective Patient Outcome for Return to Sports (SPORTS) score was collected to assess the patients' ability to return to their preinjury sporting activity. Results: The mean follow-up time was 10.1 ± 3.8 years (range, 6.1-18.8 years). Patients achieved significant pre- to postoperative improvements on the ASES (from 54.2 ± 22.6 to 83.5 ± 23.1), Rowe (from 66.6 ± 18.1 to 85.3 ± 19), Constant-Murley (from 64.6 ± 20.9 to 80.2 ± 22.7), SST (from 7.2 ± 3.4 to 10.5 ± 2.7), SANE (from 30.1 ± 23.2 to 83.6 ± 26.3), and VAS pain scores (from 4.7 ± 2.7 to 1.8 ± 2.8) (P < .001 for all), with no significant differences between type 3 and 5 injuries. At the final follow-up, patients achieved an ASOSS of 80.6 ± 32, SAS level of 11.6 ± 5.1, and SPORTS score of 7.3 ± 4.1, with no significant differences between type 3 and 5 injuries. Four patients (21.1%) had postoperative complications. Conclusion: Patients undergoing ACCR using free tendon allografts for chronic type 3 and 5 ACJ injuries maintained significant improvements in functional outcomes at the long-term follow-up and achieved favorable postoperative shoulder-sport ability, activity, and return to preinjury sports participation.

A Self-Designed Endobutton Installation Device for Coracoclavicular Stabilization in Acute Rockwood Type III Acromioclavicular Joint Dislocation.

OBJECTIVE: Endobutton technique could provide flexible coracoclavicular (CC) stabilization for acromioclavicular joint (ACJ) dislocation and achieved good clinical outcomes. However, the difficult part of this technique was placement of the Endobutton to the coracoid base. In this study, we designed an Endobutton installation device to place the Endobutton at the coracoid base. And we examined the clinical and radiographic outcomes of patients with acute Rockwood type III ACJ dislocation repaired with Endobutton using this device. METHODS: We designed an Endobutton installation device to place the Endobutton at the coracoid base to achieve CC stabilization. We retrospectively reviewed 42 patients with acute Rockwood type III ACJ dislocation who underwent CC stabilization with Endobuttons placed either using this novel device (group I, n = 19) or the traditional technique (CC stabilization without using special device, group II, n = 23) from January 2015 to April 2020. The two groups were compared regarding the operative time, intraoperative blood loss, and clinical and radiologic outcomes at final follow-up. The operation-related complications were also evaluated. The Student's t test and the Mann-Whitney U-test were used to compare differences in continuous variables. Differences in categorical variables were assessed with either the Pearson's chi-squared test or Fisher's exact test. RESULTS: Forty-two patients were clinically followed up for a minimum of 12 months. Compared with group II, group I had a significantly shorter mean operative time (56.05 ± 7.82 min vs. 65.87 ± 7.43 min, p < 0.01) and significantly lesser mean intraoperative blood loss (67.89 ± 14.75 mL vs. 94.78 ± 25.01 mL, p < 0.01). At final follow-up, there were no significant differences between the two groups in the visual analog scale score for pain, Oxford Shoulder Score, Disabilities of the Arm, Shoulder, and Hand score, and postoperative CC distance of the affected side. Loss of reduction occurred in four patients in group I and three patients in group II (p = 0.68); there were no other operation-related complications in either group. CONCLUSIONS: The Endobutton installation device makes placement of the Endobutton at the coracoid base easier and achieves satisfactory clinical and radiologic outcomes without additional complications in acute Rockwood type III ACJ dislocation.

Biomechanical Comparison of Coracoclavicular Fixation Using Metallic Versus All-Suture Anchors.

Background: A coracoclavicular (CC) fixation technique using an all-suture anchor with the assistance of fluoroscopy can prevent iatrogenic anterior deltoid detachment from the clavicle; however, soft anchor pullout has been reported as a complication. Purpose: To compare the biomechanical properties of conventional metallic and all-suture anchors for CC suture fixation. Study Design: Controlled laboratory study. Methods: A total of 24 fresh-frozen cadaveric specimens were divided into 2 groups: metal anchor group (group M) and all-suture anchor group (group A). In group M, 5.0-mm metallic suture anchors were used for CC fixation, whereas 2.8-mm all-suture anchors were used in group A. The prepared specimens were mounted on a materials testing machine. After preconditioning at 0 to 20 N for 10 cycles, the specimens were subjected to cyclic loading from 20 to 70 N for 1000 cycles. Finally, all the specimens were loaded to failure. Cyclic elongation, linear stiffness, ultimate load, and failure modes were recorded, and the Mann-Whitney U test was used to compare nonparametric parameters between the 2 groups. Results: All of the specimens completed the cyclic loading test. The elongation after cyclic loading in group M (1.6 ± 0.6 mm) was significantly smaller compared with that in group A (2.5 ± 1.2 mm) (P = .02). No between-group differences were found in linear stiffness (42 ± 17 N/mm in group M and 41 ± 17 N/mm in group A). The ultimate failure load in group M (263 ± 66 N) was significantly greater than that in group A (177 ± 76 N) (P = .02). All specimens failed because of suture anchor pullout. Conclusion: The use of all-suture anchors in CC fixation resulted in significantly greater cyclic displacement and smaller ultimate failure load than that of metallic anchors. Clinical Relevance: Understanding the most biomechanically sound suture anchor may assist in lowering the risk of clinical failure in CC fixation and repair.

Clavicular tunnel widening after coracoclavicular stabilization surgery: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis aimed to (1) estimate the prevalence of clavicular tunnel widening (TW) after coracoclavicular stabilization surgery and its risk factors and (2) assess whether TW is correlated with clavicle fracture or loss of reduction of the acromioclavicular joint (ACJ). METHODS: In January 2023, 3 electronic databases were searched to collect data on postoperative clavicular TW, its prevalence, magnitude, and correlation with fracture and ACJ loss of reduction. Studies were classified according to the time of surgical intervention, and the clavicular tunnels were categorized by their anatomic location. Mean differences were calculated using a DerSimonian-Laird random-effects model, while binomial outcomes were pooled using the Freeman-Tukey double arcsine transformation. Univariate and multivariate meta-regression analyses were performed to determine the effect of several variables on the proportion of cases with TW. RESULTS: Fifteen studies (418 shoulders) were included. At the final follow-up, evidence of clavicular TW was found in 70% (95% confidence interval [CI]: 70%-87%; I2 = 89%) of 221 shoulders. Surgeries in acute cases had a lower prevalence of TW (52%) compared to chronic cases (71%) (P < .001). Significant TW was found in the central tunnel (3.2 mm; 95% CI: 1.8-4.6 mm; P < .001; I2 = 72%) for acute injuries and in the medial (1.2 mm; 95% CI: 0.7-1.7 mm; P < .001; I2 = 77%) and lateral (1.5 mm; 95% CI: 0.7-2.3 mm; P < .001; I2 = 77%) tunnels for chronic cases. Single central-tunnel techniques were positively associated with the prevalence of TW (P = .046), while biotenodesis screw fixation was associated with a lower prevalence (P = .004) in chronic cases. Reconstruction of the ACJ ligament complex with tendon grafts or sutures was associated with a higher prevalence of TW (P < .001). Drill sizes between 2.5 and 5 mm were significantly associated with a lower prevalence of TW, regardless of injury chronicity (P = .012). No correlation was found between TW and the loss of ACJ reduction or clavicle fractures. CONCLUSIONS: This systematic review and meta-analysis explored TW occurrence following coracoclavicular stabilization surgery. TW was observed in 70% of patients at final follow-up, with a higher prevalence in chronic than in acute cases. Modifiable surgical variables, such as single-tunnel tendon graft constructs for acute or chronic injuries and knotted graft procedures for chronic injuries, were significantly associated with TW. Furthermore, the prevalence of TW increased with concomitant surgical treatment of the ACJ ligament complex, and decreased with drill sizes between 2.5 and 5 mm, regardless of lesion chronicity. These surgical variables should be considered when establishing transosseous tunnels for coracoclavicular stabilization. Clavicle fractures and TW mechanisms require further investigation.

Comparison of single versus double coracoclavicular loop stabilization technique for the management of unstable distal clavicular fractures: a randomized controlled trial.

PURPOSE: The coracoclavicular (CC) loop stabilization technique is proposed for unstable distal clavicular fractures. This study aims to compare single and double CC loop stabilizations and evaluate differences in functional and radiographic outcomes between them. METHODS: We conducted a prospective randomized controlled trial involving 46 patients who sustained unstable distal clavicular fractures between April 2017 and 2019. The participants were randomly assigned to one of two groups: the single CC loop stabilization group (n = 23) or the double CC loop stabilization group (n = 23). We assessed their Constant score, American Shoulder and Elbow Surgeons score (ASES), and pain level. Additionally, we recorded data on time to union, CC distance, and any complications. RESULTS: The single CC loop group demonstrated a shorter operative time and significantly higher Constant score than the double CC loop group at 1 month (77.32 ± 5.65 vs. 71.91 ± 8.33; p = 0.016) and 3 months (86.17 ± 4.05 vs. 81.13 ± 6.34; p = 0.009) postoperatively. However, there was no differences in the ASES score, time to union or CC distance restoration between two groups. Implant irritation was observed in the double CC loop group (26.1%), but there were no cases requiring revision surgery. CONCLUSIONS: Both single and double CC loop stabilization demonstrated favorable outcomes, including a high union rate and minimal complications. Single CC loop stabilization showed slightly better early functional outcomes, reduced implant-related irritation, and shorter operative times.