Is AC TightRope fixation better than Bosworth screw fixation for minimally invasive operative treatment of Rockwood III AC joint injury?

INTRODUCTION: Injuries to the acromioclavicular (AC) joint are common in sports participants and may lead to instability or degenerative changes that require surgical intervention. Diagnostics include X-ray projections; MRI could also be a useful method. Surgical treatment of acute Rockwood type III AC dislocation varies on a case-by-case basis and includes coracoclavicular (CC) stabilisation with two techniques of minimal invasive fixation: the Bosworth screw and AC TightRope fixation (Arthrex, US). The aim of this study was to analyse whether there is a difference between these two surgical procedures in the quality of repair of CC ligaments by comparing preoperative and postoperative AC joint radiological and clinical findings. PATIENTS AND METHODS: In this study, we evaluated our 5 years' experience of surgical management of Rockwood type III AC dislocation. Radiological analyses included measurement of CC distance at the AC joint, X-ray and MRI evaluation of CC ligament scar tissue continuity; clinical outcome was assessed using the Constant Murley, Oxford Shoulder and DASH scores preoperatively and during 6 months of postoperative follow-up. RESULTS: A total of 68 patients with Rockwood type III AC dislocation were treated surgically with minimally invasive CC fixation using either the AC TightRope implant (34 patients, TR group) or the Bosworth screw (34 patients, BS group) in a prospective, randomised clinical trial. There was no statistically significant difference in radiological X-ray and MRI evaluations of postoperative results between the two groups of patients at the end of follow-up. Patients in the TR group reported significantly less inconvenience with treatment as the patients in the BS group had to undergo a second operation to remove the Bosworth screw. Postoperative recurrence of dislocation was observed in two patients in the TR group (5.88%) and in four patients in the BS group (11.76%) 6 months postoperatively. The difference between the two groups was not statistically significant (p=0.4). CONCLUSION: MRI could be a useful method to evaluate quality of repair of CC ligaments. The minimally invasive surgical techniques used in this study showed similar radiological and clinical efficacy in the treatment of acute Rockwood type III AC dislocation, but AC TightRope fixation provided patients with significantly more treatment satisfaction and less inconvenience than Bosworth screw fixation.

Staged management of knee dislocation in polytrauma injured patients.

INTRODUCTION: Knee dislocation in the polytrauma setting is rare. The optimal method that this injury should be managed remains controversial. We therefore undertook a study to evaluate the incidence and outcomes of knee dislocation in polytrauma patients treated in our institution. PATIENTS AND METHODS: From January 2005 to February 2011, two hundred-seventy five polytrauma patients were managed in our institution. Knee dislocation was present in 14 patients (4%): 4 females, mean age 46 years (range 19-52), mean ISS 24 (range 18-34) and 10 males, mean age 45 years (18-48), mean ISS 28 (range 18-48). Knee dislocation was classified according to the Schenck classification. MRI was used routinely for accurate assessment of the knee lesions. Treatment protocol consisted of initially management with the ATLS guidelines, neurovascular assessment, emergency surgical care simultaneously with reanimation procedures and hospitalization at ICU. Upon full evaluation and stabilization of the patient's physiological status and acquisition of a knee MRI scan, one- to three-stage operative treatment was performed. Decision for one- or more-stage treatment was based on the evaluation of the systemic and local clinical status, injury classification, timing of surgery, and consequences that remained after associated injuries. Clinical outcome was evaluated by IKDC 2000 Subjective knee evaluation, IKDC Clinical Examination Scales and the Tegner-Lysholm scale. A specific accelerated rehabilitation program was completed according to the surgical treatment. The mean follow up was 2 years (range 19-48 months). RESULTS: Patients had a different type of knee dislocations: five KD II, six KD III, two KD V2 and one KD V3. Clinical results were low in patients that underwent the three-staged protocol, and good and high in one- or two-staged operative treatment respectively at the two year follow up. The difference between the results in three groups of treated patients was visible but not statistically significant. CONCLUSION: The physiological state of the patient along with the type of knee lesion dictates a timing and type of stage treatment. The best postoperative clinical results are fulfilled with the one-stage treatment and it should be the first choice of knee dislocation therapy. Two-stage treatment should be performed only if the general clinical status of polytrauma injured patient or local knee status does not allow a complete knee reconstructive surgery. Three-stage treatment results with the worst outcome and it should be avoided.