Discussion
Rockwood II and III were the most frequently seen ACJ injuries in The Netherlands. The diagnosis was mainly based on physical examination (91%) and radiographs (95%). The Rockwood classification was used the most. Rockwood II and III ACJ injuries were usually treated non-operatively, whereas Rockwood IV and V ACJ injuries were usually treated operatively. Patient factors contributing to the decision for operative treatment were mainly functional need and age. A flexible implant (e.g., Lockdown™) was preferred for primary and secondary operative treatment. Distal clavicle resection was more often deemed necessary during secondary than during primary operative treatment. All respondents agreed that nonoperative treatment of Rockwood II ACJ injuries leads to satisfactory results and that just rarely secondary operative treatment is required. The percentage of Rockwood III ACJ injuries requiring a secondary surgical intervention seemed higher, and the expected cosmetic result of non-operatively treated Rockwood III ACJ injuries was reported as less satisfactory. Hootman reported in a follow-up study of a previous review, that the evidence does not support (immediate) surgical treatment of grade III AC dislocations with respect to overall patient satisfaction as well as clinical outcomes such as pain, range of motion, and strength [
13,
14]. Similar as in the current study, over 80% of patients with an ACJ type III injury treated non-operatively achieved satisfactory functional results and did not require surgery. Also, the Canadian Orthopaedic Trauma Society showed in a prospective randomized clinical trial good or excellent long term results of non-operative treatment of Rockwood III ACJ injuries, however, compared to Hook plate fixation [
15].
Literature reports Rockwood II, III, and V to be the most common types of ACJ injuries [
3].
It is unclear why the respondents in the current study report a lower rate of occurrence of Rockwood V ACJ injuries. The diagnostic approach reported by the respondents is in line with the literature. A systematic review showed high inter- and intra-observer reliability for diagnosing vertical instabilities of the clavicle using X-ray alone. Reliability for horizontal instabilities is much more variable [
16].
Functional need (88%) and age (86%) were the most important patient-related factors to decide for operative management. In line with current general opinion, cosmesis (18%) seemed not to play a significant role in this decision. However, the cosmetic consequence of a completely displaced ACJ joint is hard to ignore. The respondents indeed expected patients with Rockwood III ACJ injuries to be less satisfied with cosmetic results. In a recent review, Chang et al. reported a poor cosmesis in both operative and nonoperative patients [
8]. Hypertrophic or prominent scars were the most common complaint in the operative group, whereas deformity of the shoulder was more prevalent in the nonoperative group. Overall, cosmetic outcomes favored the operative group. Chang et al. emphasized that the idea of a poor cosmetic result is individual and subjective and does not necessarily correlate with the reduction of the AC joint [
8].
Surprisingly, approximately a third of the respondents would not treat Rockwood IV and V ACJ dislocations primarily operatively. This is in contradiction with the general recommendation for primary operative treatment of Rockwood type IV to VI lesions, although the level of evidence of this recommendation is low [
17‐
19]. A recent study found no correlation between Rockwood grade and clinical symptoms, suggesting that the reliability of using the Rockwood grade as a decision-making tool in the management of acute AC joint dislocation is unclear [
20].
Whereas operative treatment is generally advised for Rockwood V ACJ injuries, the treatment of Rockwood III ACJ dislocations is still debated. Sixty-three (59%) respondents would treat a Rockwood III different than a Rockwood V ACJ injury, but only nine reported to base this distinction on additional radio-diagnostic tests. The data do not provide further details as to how they did make the distinction. In a small case study, it was found that MRI can allow the good anatomical display of ACJ structures and can give clinically relevant information on type and extension of ACJ injury [
21]. In our survey, only two respondents used MRI and one used ultrasound for this purpose.
Previous studies have reported physiological clavicle rotations up to 30 degrees during shoulder abduction, elevation, retraction, and backward rotation [
22‐
26]. Flexible implants allow the clavicle to move in a more or less natural anatomical fashion relative to the scapula. The vast majority of respondents recognized this phenomenon and use these implants in both primary and secondary operative treatment of any ACJ injury. For secondary surgery, flexible implants were often combined with a Weaver–Dunn procedure [
27]. The array of implants used in the Netherlands is in line with previous publications [
5‐
7]. Boffano et al. concluded that there is no consensus on the implant use, but suggest to treat young patients with high-grade ACJ injuries in the early stages using synthetic devices with open or arthroscopic procedures aiming to obtain a stable joint [
5].
Rigid coracoclavicular screw fixation appears to be abandoned in the Netherlands. Rigid fixation of the clavicle to the scapula is non-physiological and hinders normal shoulder function for the period that the implant is present. This implicates that studies comparing flexible implants with nonoperative management might result more in favor of operative management than the available studies comparing rigid fixation techniques with nonoperative management.
Distal clavicle resection is more often considered necessary in secondary operative treatment. The reason for that might be shortening of the shoulder during nonoperative management of unstable ACJ injuries, hence the strut-function of the clavicle is lost after complete ACJ dislocation. Hillen et al. showed in a cadaveric study that clavicle shortening results in changes of maximal muscle moments around the shoulder girdle [
28]. Nonoperative management of an unstable ACJ injury could have the same effect, resulting in shortening of muscles of the shoulder and inability to reduce the AC joint without too much tension. However, no high-quality clinical studies are present in this hypothesis.
With only two respondents considering to refer their patient to a colleague for expertise, there seems no need for centralization of this topic in The Netherlands.
A limitation of the current study is that, as is inherent to questionnaires, the level of scientific evidence is low.
Acknowledgements
Dr. N.W.L. Schep (Maasstad Ziekenhuis, Rotterdam, The Netherlands) and Dr. D. Den Hartog (Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands) are greatly acknowledged for their feedback during the development of the survey. ACJ injury study group: Bartlema K.A. (LUMC, Leiden, The Netherlands), Been J. (Ziekenhuisgroep Twente, Almelo, The Netherlands), Biert J. (Radboud UMC, Nijmegen, The Netherlands), Boer R. (Amphia Ziekenhuis, Breda, The Netherlands), Bronkhorst M.W.G.A. (Haaglanden Medisch Centrum, The Hague, The Netherlands), Campo M.M. (Ikazia Ziekenhuis, Rotterdam, The Netherlands), De Vries J.S. (Ziekenhuis Amstelland, Amstelveen, The Netherlands), Derksen R.J. (Zaans Medisch Centrum, Zaandam, The Netherlands), Dijkstra A.J. (Flevoziekenhuis, Almere, The Netherlands), Eggen P.J.M.G. (Elkerliek Ziekenhuis, Helmond, The Netherlands), Eversdijk M.G. (Ziekenhuis St. Jansdal, Harderwijk, The Netherlands), Feczko P.Z. (MUMC+, Maastricht, The Netherlands), Flikweert P.E. (Hagaziekenhuis, The Hague, The Netherlands), Garssen F.P. (Ziekenhuis Amstelland, Amstelveen, The Netherlands), Gosens T. (Elisabeth TweeSteden Ziekenhuis, Tilburg, The Netherlands), Goslings J.C. (AMC, Amsterdam, The Netherlands), Groot N. (Diaconessehuis, Meppel, The Netherlands), Haverlag R. (OLVG, Amsterdam, The Netherlands), Heetveld M.J. (Spaarne Gasthuis, Haarlem, The Netherlands), Hillen R.J. (Waterland Ziekenhuis, Purmerend, The Netherlands), Hoelen M.A. (Reinier de Graag Groep, Delft, The Netherlands), Hollanders R.M.F. (Slingeland Ziekenhuis, Doetinchem, The Netherlands), Hoogendoorn J.M. (Haaglanden Medisch Centrum, The Hague, The Netherlands), Jansen E.J.P. (Zuyderland Ziekenhuis, Heerlen, The Netherlands), Janzing H.J. (VieCuri Medisch Centrum, Venlo, The Netherlands), Jaspars K.C.C.J. (Van Weel-Bethesda Ziekenhuis, Dirksland, The Netherlands), Jenner J.M.G.Th. (Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands), Kloen P. (AMC, Amsterdam, The Netherlands), Koorevaar C.T. (Deventer Ziekenhuis, Deventer, The Netherlands), Kuipers N.M. (Antoniusziekenhuis, Sneek, The Netherlands), Lisowski L.A. (BovenIJ Ziekenhuis, Amsterdam, The Netherlands), Lubbert P.H.W. (Ziekenhuis De Tjongerschans, Heerenveen, The Netherlands), Meuffels D.E. (Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands), Mollen R.M.H.G. (Ziekenhuis Gelderse Vallei, Ede, The Netherlands), Nagel P.H.A.F. (Rode Kruis Ziekenhuis, Beverwijk, The Netherlands), Onstenk R. (Groene Hart Ziekenhuis, Gouda, The Netherlands), Poelhekke L.M.S.J. (Maasziekenhuis Pantein, Boxmeer, The Netherlands), Postma V.A. (Ziekenhuis St. Jansdal, Harderwijk, The Netherlands), Riedijk R. (Tergooi Ziekenhuizen, Hilversum, The Netherlands), Rijk P.C. (Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands), Roerdink W.H. (Deventer Ziekenhuis, Deventer, The Netherlands), Rutten S. (Franciscus Gasthuis&Vlietland, Rotterdam, The Netherlands), Schep N.W.L. (Maasstad Ziekenhuis, Rotterdam, The Netherlands), Sintenie J.B. (Elkerliek Ziekenhuis, Helmond, The Netherlands), Stevens C.T. (Ziekenhuis Bernhoven, Uden, The Netherlands), Teijgeler H.M. (Tergooi Ziekenhuizen, Hilversum, The Netherlands), Ten Cate W.A. (Ziekenhuisgroep Twente, Almelo, The Netherlands), Ten Holder E.J.T. (IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands), Ter Keurs D. (Gelreziekenhuizen, Apeldoorn, The Netherlands), Twigt B.A. (BovenIJ Ziekenhuis, Amsterdam, The Netherlands), Van Arkel E.B.A. (Haatlanden MC, The Hague, The Netherlands), Van de Linde P. (Van Weel-Bethesda Ziekenhuis, Dirksland, The Netherlands), Van de Schoot L. (Beatrixziekenhuis, Gorinchem, The Netherlands), Van den Brand J.G.H. (Noordwest Ziekenhuis Groep, Alkmaar, The Netherlands), Van der Elst M. (Reinier de Graaf Groep, Delft, The Netherlands), Van der Veen A.H. (Catharina Ziekenhuis, Eindhoven, The Netherlands), Van der Zwaal P. (Haaglanden MC, The Hague, The Netherlands), Van Deurzen D.F.P. (OLVG, Amsterdam, The Netherlands), Van Dijkman B.A. (Flevoziekenhuis, Almere, The Netherlands), Van Dulken E.J. (Slotervaart Ziekenhuis, Amsterdam, The Netherlands), Van Eerten P.V. (Maxima Medisch Centrum, Veldhoven, The Netherlands), Van Helden S.H. (Isala Klinieken, Zwolle, The Netherlands), Van Olden G.D.J. (Meander Medisch Centrum, Amersfoort, The Netherlands), Van Oostveen D.P.H. (Jeroen Bosch Ziekenhuis, Den Bosch, The Netherlands), Van Stigt S.F.L. (Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands), Van Wessem K.J.P. (Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands), Verbruggen J.P.A.M. (MUMC+, Maastricht, The Netherlands), Verlaan L. (Catharina Ziekenhuis, Eindhoven, The Netherlands), Visser C.P.J. (Alrijne Ziekenhuis, Leiderdorp, The Netherlands), Vos D.I. (Amphia Ziekenhuis, Breda, The Netherlands), Wessel R.N. (St. Antonius Ziekenhuis, Nieuwgein, The Netherlands), Wiendels D.R. (Ziekenhuis Rivierenland, Tiel, The Netherlands), Winkelhagen J. (Westfriesgasthuis, Hoorn, The Netherlands), Winkelhorst J.T. (Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands), Wittich Ph. (St. Antonius Ziekenhuis, Nieuwegein, The Netherlands), Zuidema W.P. (VU Medisch Centrum, Amsterdam, The Netherlands), Zuurmond R.G. (Isala Klinieken, Zwolle, The Netherlands).