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      New insights in the treatment of acromioclavicular separation

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          Abstract

          A direct force on the superior aspect of the shoulder may cause acromioclavicular (AC) dislocation or separation. Severe dislocations can lead to chronic impairment, especially in the athlete and high-demand manual laborer. The dislocation is classified according to Rockwood. Types I and II are treated nonoperatively, while types IV, V and VI are generally treated operatively. Controversy exists regarding the optimal treatment of type III dislocations in the high-demand patient. Recent evidence suggests that these should be treated nonoperatively initially. Classic surgical techniques were associated with high complication rates, including recurrent dislocations and hardware breakage. In recent years, many new techniques have been introduced in order to improve the outcomes. Arthroscopic reconstruction or repair techniques have promising short-term results. This article aims to provide a current concepts review on the treatment of AC dislocations with emphasis on recent developments.

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          Current concepts in the treatment of acromioclavicular joint dislocations.

          Knut Beitzel, P Côté, Augustus Mazzocca … (2013)
          To conduct a systematic review of the literature in relation to 3 considerations in determining treatment options for patients with acromioclavicular (AC) joint dislocations: (1) operative versus nonoperative management, (2) early versus delayed surgical intervention, and (3) anatomic versus nonanatomic techniques. The PubMed database was searched in October 2011 using the single term acromioclavicular and the following search limits: any date, humans, English, and all adult (19+). Studies were included if they compared operative with nonoperative treatment, early with delayed surgical intervention, or anatomic with nonanatomic surgical techniques. Exclusion criteria consisted of the following: Level V evidence, laboratory studies, radiographic studies, biomechanical studies, fractures or revisions, meta-analyses, and studies reporting preliminary results. This query resulted in 821 citations. Of these, 617 were excluded based on the title of the study. The abstracts and articles were reviewed, which resulted in the final group of 20 studies that consisted of 14 comparing operative with nonoperative treatment, 4 comparing early with delayed surgical intervention, and 2 comparing anatomic with nonanatomic surgical techniques. The lack of higher level evidence prompted review of previously excluded studies in an effort to explore patterns of publication related to operative treatment of the AC joint. This review identified 120 studies describing 162 techniques for operative reconstruction of the AC joint. There is a lack of evidence to support treatment options for patients with AC joint dislocations. Although there is a general consensus for nonoperative treatment of Rockwood type I and II lesions, initial nonsurgical treatment of type III lesions, and operative intervention for Rockwood type IV to VI lesions, further research is needed to determine if differences exist regarding early versus delayed surgical intervention and anatomic versus nonanatomic surgical techniques in the treatment of patients with AC joint dislocations. Level III, systematic review of Level II and Level III studies and one case series. Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
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            Treatment of acromioclavicular injuries, especially complete acromioclavicular separation.

            Donald Weaver, Malcolm H. Dunn (1972)
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              Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations.

              Markus Scheibel, Silvia Dröschel, Christian Gerhardt … (2011)
              The purpose of this study was to evaluate the clinical and radiological results after arthroscopically assisted and image intensifier--controlled stabilization of high-grade acromioclavicular (AC) joint separations using the double TightRope technique with the first-generation implant. The double TightRope technique using the first-generation implant leads to good clinical and radiological results by re-creating the anatomy of the AC joint. Case series; Level of evidence, 4. Thirty-seven consecutive patients (4 women and 33 men; mean age, 38.6 years) who sustained an acute AC joint dislocation grade V according to Rockwood were included in this prospective study. The Subjective Shoulder Value (SSV), the Constant Score (CS), the Taft Score (TS), and a newly developed Acromioclavicular Joint Instability Score (ACJI) were used for final follow-up. Bilateral stress views and bilateral Alexander views were taken to evaluate radiographic signs of recurrent vertical and horizontal AC joint instability. Twenty-eight patients (2 women and 26 men; mean age, 38.8 years [range, 18-66 years]) could be evaluated after a mean follow-up of 26.5 months (range, 20.1-32.8 months). The interval from trauma to surgery averaged 7.3 days (range, 0-18 days). The mean SSV reached 95.1% (range, 85%-100%), the mean CS was 91.5 points (range, 84-100) (contralateral side: mean, 92.6 points), the mean TS was 10.5 points (range, 7-12), and the ACJI averaged 79.9 points (range, 45-100). The final coracoclavicular distance was 13.6 mm (range, 5-27 mm) on the operated versus 9.4 mm (range, 4-15 mm) on the contralateral side (P < .05). Radiographic signs of posterior instability were noted in 42.9% of cases. Patients with evidence of posterior instability had significantly inferior results in the TS and the ACJI (P < .05). Neither coracoid fractures nor early (within 6 weeks postoperatively) loss of reduction due to tunnel malpositioning or implant loosening was observed. The combined arthroscopically assisted and image intensifier--controlled double TightRope technique using implants of the first-generation represents a safe technique and yields good to excellent early clinical results despite the presence of partial recurrent vertical and horizontal AC joint instability.
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                Author and article information

                Contributors
                Christiaan J A van Bergen
                Annelies F van Bemmel
                Tjarco D W Alta
                Arthur van Noort
                Journal
                Journal ID (nlm-ta): World J Orthop
                Journal ID (publisher-id): WJO
                Title: World Journal of Orthopedics
                Publisher: Baishideng Publishing Group Inc
                ISSN (Electronic): 2218-5836
                Publication date Collection: 18 December 2017
                Publication date (Electronic): 18 December 2017
                Volume: 8
                Issue: 12
                Pages: 861-873
                Affiliations
                Department of Orthopaedic Surgery, Amphia Hospital, Breda 4818 CK, The Netherlands
                Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp 2134 TM, The Netherlands
                Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp 2134 TM, The Netherlands
                Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp 2134 TM, The Netherlands
                Author notes

                Author contributions: All authors equally contributed to this paper with conception and design, literature review and analysis, drafting and critical revision and editing, and approval of the final version.

                Correspondence to: Christiaan J A van Bergen, MD, PhD, Surgeon, Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, Breda 4818 CK, The Netherlands. cvanbergen@ 123456amphia.nl

                Telephone: +31-76-5955000

                Article
                Other ID: jWJO.v8.i12.pg861
                DOI: 10.5312/wjo.v8.i12.861
                PMC ID: 5745428
                SO-VID: dcdd7ee8-b32d-47a5-9076-2741bd65dd59
                Copyright © ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
                License:

                Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 22 August 2017
                Date revision received : 27 November 2017
                Date accepted : 5 December 2017
                Categories
                Subject: Minireviews

                Keywords: acromioclavicular dislocation,rockwood classification,coracoclavicular ligament reconstruction,hookplate,arthroscopically assisted acromioclavicular reconstruction,weaver and dunn procedure,conoid and trapezoid ligaments
                Data availability:
                Keywords: acromioclavicular dislocation, rockwood classification, coracoclavicular ligament reconstruction, hookplate, arthroscopically assisted acromioclavicular reconstruction, weaver and dunn procedure, conoid and trapezoid ligaments

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