Current concepts in management of ACJ injuries

doi:10.1016/j.jcot.2019.03.020

Journal of Clinical Orthopaedics and Trauma

Volume 10, Issue 3, May–June 2019, Pages 480-485

https://doi.org/10.1016/j.jcot.2019.03.020 Get rights and content

Abstract

Acromioclavicular joint injury is common in young individuals who suffer direct trauma to the shoulder. Treatment of acromioclavicular dislocation is controversial with regards to the indication of operative management, timing of surgery, whether to perform open or arthroscopic surgery, method of stabilisation (rigid or non-rigid) and type of graft used for repair or reconstruction. Current evidence supports conservative management for Rockwood types I and II, while types IV, V and VI benefit from surgery. The optimal management of type III injuries in high demand patients remains contentious. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Few studies with a low level of evidence suggest arthroscopic techniques and anatomical ligament reconstruction have better outcomes when compared to older techniques of rigid coracoclavicular fixation. The aim of this article is to look at the current evidence and address these controversial issues.

Introduction

The acromio-clavicular (AC) joint is a di-arthrodial joint which acts as a link between axial and appendicular skeleton and contributes to the complex pattern of movement of the shoulder joint. AC joint injuries are most commonly seen in young adults and about 43% of injuries occur in second decade of life. AC joint injuries are 5 times more common in men and often involve contact sports.¹^,² Despite being a common injury, there is no consensus regarding optimal management of AC joint dislocation. In recent years numerous techniques have been developed and described. Controversy exists regarding the choice of surgical procedure for treatment of injuries and the timing of surgery.³^,⁴ The following work attempts to review literature regarding recent developments in the treatment of acute AC joint injuries and provide recommendations based on sound clinical evidence.

The AC joint is a synovial joint and its articular surface is made up of hyaline cartilage with an interposed disc of cartilage identical to a meniscus. This meniscus undergoes attrition over-time and is practically absent by the fourth decade of life. The articular surface area is small, whereas load transmitted is high. Cadaveric study of AC joint morphology has demonstrated three main types of AC joints 1)Flat, 2)Oblique and 3)Curved (Fig. 1).⁵ The forces are uniformly distributed in a flat acromion, however a curved or an oblique joint may have asymmetric stress transfer promoting damage to the articular cartilage.

The AC joint is stabilised by the AC ligaments which are thickenings in the joint capsule and the coraco-clavicular (CC) ligaments. The joint experiences significant translational forces in the anteroposterior and superolateral directions due to weight of the arm and muscle pull. The AC ligament provides about 90% of the AP stability and 20–50% of resistance to superior migration. The CC ligament consists of the conoid ligament medially and the trapezoid laterally. They are the primary restraint to inferior and medial translation of the acromion in respect to the clavicle.⁶

Section snippets

Classification

The sequential pattern of injury beginning with the AC ligaments, progressing to the coraco-clavicular ligaments and finally involving the deltoid and trapezial muscles was originally described by Cadenat.⁷ Rockwood described a classification which is most commonly accepted presently (Fig. 2).² In type I injury, the AC and CC ligaments are all intact and the radiographic examination is normal. In type II injuries, the force of trauma is severe enough to rupture the AC ligaments, yet not severe

Acromioclavicular fixation

Acromio-clavicular fixation allows healing of the disrupted coraco-acromial ligaments by restoring the distance between the clavicle and the coracoid. Satisfactory outcomes have been reported in literature with Kirchner Wire (K wire) fixation and ligament repair. However, the procedure is rarely used today because of high incidence of migration of K wires and loss of reduction.¹⁵^,¹⁶

Coraco-clavicular fixation

The coraco-clavicular distance can be maintained either by rigid fixation with a screw or the use of non-rigid synthetic materials. Bosworth described coraco-clavicular stabilisation with a lag screw.²³ Rockwood and Young modified the technique to include CC ligament repair or reconstruction depending on the time of surgery. A bicortically placed screw provides about 80% more strength than the native ligament.²⁴ However, this technique does not allow the clavicle to move in relation to the

Ligament reconstruction

The Weaver-Dunn procedure involves stabilisation of the AC joint by transfer of native CA ligament from acromion to the distal clavicle. The original technique also included excision of the distal clavicle. Initial reports from Weaver and Dunn revealed a 75% good-excellent outcome.²⁸ Biomechanical studies have demonstrated that the native CA ligament is weakest amongst the various constructs tested.²⁹ The initial strength of the CA ligament construct was found to be only a quarter of the native

Conclusion

In the recent years there has been an exponential increase in the number of publications on repair and reconstruction of AC joint.⁴⁸ However, most of the recent studies are case series and lack long-term follow-up. Lack of standardisation in terms of population homogeneity, severity and chronicity of the injury prevents drawing up recommendations based on sound evidence. Significant questions still remain unanswered, with regards to type of graft to be used, number of ligaments reconstructed,

Declaration of interest

None.

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Cited by (38)

[Translated article] Type III acromioclavicular dislocation: Mid term results after operative and non-operative treatment
2024, Revista Espanola de Cirugia Ortopedica y Traumatologia
Controversy exists in the literature about the best treatment for type III acromioclavicular dislocations. The aim of this study is to compare functional results between surgical and conservative treatment in type III acromioclavicular joint dislocations.
We retrospectively evaluated the records of 30 patients from our area with acute type III acromioclavicular dislocations that were treated from January 1st, 2016 to December 31st, 2020. Fifteen patients were treated surgically and 15 conservatively. Follow-up mean time was 37.93 months in operative group and 35.73 months in non-operative group. Results obtained on the Constant score was the main variable analysed and results obtained on the Oxford score and the Visual Analogue Scale for pain were the secondary variables. Epidemiological variables were analysed, as well as range of mobility in injured shoulder and subjective and radiological variables (distance between the superior border of the acromion and the superior border of the clavicle's distal end and presence of osteoarthritis in the acromioclavicular joint).
Functional evaluation scores did not show differences between the two groups (Constant: operative 82/non-operative 86.38, p 0.412; Oxford: operative 42/non-operative 44.80, p 0.126) nor did Visual Analogue Scale (operative 1/non-operative 0.20, p 0.345). Subjective evaluation of the injured shoulder was excellent or good in 80% of the patients in both groups. Measurement of the distance between the superior border of the acromion and the superior border of the clavicle's distal end were significantly higher in non-operative group (operative 8.95/non-operative 14.21, p 0.008).
Although radiographic results were better in the surgical treatment group, functional evaluation scores did not show significant differences between the two groups. These results do not support the routine use of surgical treatment for grade III acromioclavicular dislocations.
Existe controversia en la literatura sobre el tratamiento más adecuado para las luxaciones acromioclaviculares (LAC) tipo III. El objetivo principal de este estudio es comparar el resultado funcional a medio plazo de los pacientes con esta patología manejados de forma conservadora y mediante tratamiento quirúrgico.
Se evaluaron de forma retrospectiva los datos de 30 pacientes con LAC tipo III desde el 1 de enero del 2016 hasta el 31 de diciembre del 2020. Se trató de forma quirúrgica a 15 pacientes y otros 15 se abordaron de manera conservadora. El tiempo de seguimiento medio fue de 37,93 meses en el grupo de tratamiento quirúrgico y de 35,73 meses en el grupo de tratamiento conservador. La variable principal estudiada fue el resultado obtenido en la escala Constant; los resultados de la escala de Oxford y la escala visual analógica (EVA) para el dolor fueron las variables secundarias. Se analizaron variables epidemiológicas, rango de movimiento del hombro, variables subjetivas y radiológicas (distancia entre el borde superior del acromion y el borde superior del extremo distal de la clavícula y presencia de cambios degenerativos en la articulación acromioclavicular).
No se encontraron diferencias significativas entre ambos grupos en las escalas de evaluación funcional (Constant: quirúrgico 82/no quirúrgico 86,38, p = 0,412; Oxford: quirúrgico 42/no quirúrgico 44,80, p = 0,126) ni en la escala EVA para el dolor (quirúrgico 1/no quirúrgico 0,20, p = 0,345). En ambos grupos, la evaluación subjetiva del resultado fue buena o excelente en 80% de los casos. La distancia entre el borde superior del acromion y el borde superior del extremo distal de la clavícula fue significativamente mayor en el grupo de tratamiento conservador (quirúrgico 8,95/no quirúrgico 14,21, p = 0,008).
A pesar de que los resultados radiográficos fueron mejores en el grupo de tratamiento quirúrgico, las escalas de evaluación funcional no mostraron diferencias significativas entre ambos grupos. Estos resultados no apoyan el tratamiento quirúrgico de forma rutinaria para el tratamiento de las LAC tipo III.
Acromioclavicular joint injuries: a review of pathoanatomy, assessment and current management approaches
2023, Orthopaedics and Trauma
Acromioclavicular joint (ACJ) injuries represent approximately 10% of all shoulder girdle injuries and their assessment and management can be clinically challenging. This may be for several reasons, including a lack of consensus concerning the reliability of the classification systems, contributing to suboptimal clinical outcomes. A paucity of literature regarding predictive factors for ACJ pathology may also be a factor. Controversy regarding conservative versus surgical management to provide optimal care also continues to be a factor in this clinical challenge, as similar results have been shown with both approaches. There is consensus that low-grade injuries can be treated with non-operative management, but some will go on to have long-term complications. However, the risks of surgical intervention may not out-weigh the benefits. In higher grade injuries there is further controversy over conservative versus surgical management. Improved classification systems and shared decision-making to individualize treatment plans are likely to improve patient outcomes. This review provides an overview of current assessment and management of ACJ injuries in adults.
Risk for Fracture with Acromioclavicular Joint Reconstruction and Strategies for Mitigation
2023, Clinics in Sports Medicine
Management of Acromioclavicular Joint Injuries: A Historic Account
2023, Clinics in Sports Medicine
Type III acromioclavicular dislocation: Mid term results after operative and non-operative treatment
2023, Revista Espanola de Cirugia Ortopedica y Traumatologia
Existe controversia en la literatura sobre el tratamiento más adecuado para las luxaciones acromioclaviculares (LAC) tipo III. El objetivo principal de este estudio es comparar el resultado funcional a medio plazo de los pacientes con esta patología manejados de forma conservadora y mediante tratamiento quirúrgico.
Se evaluaron de forma retrospectiva los datos de 30 pacientes con LAC tipo III desde el 1 de enero del 2016 hasta el 31 de diciembre del 2020. Se trató de forma quirúrgica a 15 pacientes y otros 15 se abordaron de manera conservadora. El tiempo de seguimiento medio fue de 37,93 meses en el grupo de tratamiento quirúrgico y de 35,73 meses en el grupo de tratamiento conservador. La variable principal estudiada fue el resultado obtenido en la escala de Constant; los resultados de la escala de Oxford y la escala visual analógica (EVA) para el dolor fueron las variables secundarias. Se analizaron variables epidemiológicas, rango de movimiento del hombro, variables subjetivas y radiológicas (distancia entre el borde superior del acromion y el borde superior del extremo distal de la clavícula y presencia de cambios degenerativos en la articulación acromioclavicular).
No se encontraron diferencias significativas entre ambos grupos en las escalas de evaluación funcional (Constant: quirúrgico 82/no quirúrgico 86,38, p = 0,412; Oxford: quirúrgico 42/no quirúrgico 44,80, p = 0,126) ni en la escala EVA para el dolor (quirúrgico 1/ no quirúrgico 0,20, p = 0,345). En ambos grupos, la evaluación subjetiva del resultado fue buena o excelente en el 80% de los casos. La distancia entre el borde superior del acromion y el borde superior del extremo distal de la clavícula fue significativamente mayor en el grupo de tratamiento conservador (quirúrgico 8,95/no quirúrgico 14,21, p = 0,008).
A pesar de que los resultados radiográficos fueron mejores en el grupo de tratamiento quirúrgico, las escalas de evaluación funcional no mostraron diferencias significativas entre ambos grupos. Estos resultados no apoyan el tratamiento quirúrgico de forma rutinaria para el tratamiento de las LAC tipo III.
Controversy exists in the literature about the best treatment for type III acromioclavicular dislocations. The aim of this study is to compare functional results between surgical and conservative treatment in type III acromioclavicular joint dislocations.
We retrospectively evaluated the records of 30 patients from our area with acute type III acromioclavicular dislocations that were treated from January 1st, 2016 to December 31st, 2020. Fifteen patients were treated surgically and 15 conservatively. Follow up mean time was 37.93 months in operative group and 35.73 months in non-operative group. Results obtained on the Constant score was the main variable analysed and results obtained on the Oxford score and the Visual Analogue Scale for pain were the secondary variables. Epidemiological variables were analysed, as well as range of mobility in injured shoulder and subjective and radiological variables (distance between the superior border of the acromion and the superior border of the clavicle's distal end and presence of osteoarthritis in the acromioclavicular joint).
Functional evaluation scores did not show differences between the two groups (Constant: operative 82/non-operative 86.38, p 0.412; Oxford: operative 42/non-operative 44.80, p 0.126) nor did Visual Analogue Scale (operative 1/non-operative 0.20, p 0.345). Subjective evaluation of the injured shoulder was excellent or good in 80% of the patients in both groups. Measurement of the distance between the superior border of the acromion and the superior border of the clavicle's distal end were significantly higher in non-operative group (operative 8.95/non-operative 14.21, p 0.008).
Although radiographic results were better in the surgical treatment group, functional evaluation scores did not show significant differences between the two groups. These results do not support the routine use of surgical treatment for grade III acromioclavicular dislocations.
Delayed acromioclavicular joint reconstruction using a modern suspensory device does not increase the risk of fixation failure or major complications
2022, Journal of Shoulder and Elbow Surgery
Management of displaced acromioclavicular joint (ACJ) injuries remains contentious. It is unclear if delayed vs. acute reconstruction has an increased risk of fixation failure and complications. The primary aim of this study was to compare complications of early vs. delayed reconstruction. The secondary aim was to determine modes of failure of ACJ reconstruction requiring revision surgery.
A retrospective study was performed on all patients who underwent operative reconstruction of ACJ injuries over a 10-year period (Rockwood III-V) using suspensory devices with or without hamstring allograft. Reconstruction was classed as early (<12 weeks from injury) or delayed (≥12 weeks). Patient demographics, fixation method, and postoperative complications were noted, with 1-year follow-up a minimum requirement for inclusion. Patient-reported outcomes with the Disabilities of the Arm, Shoulder, and Hand score and EuroQol-5 Dimension were undertaken. Fixation failure was defined as loss of reduction requiring revision surgery.
A total of 104 patients were analyzed (n = 59 early and n = 45 delayed). The mean age was 42.0 (standard deviation: 11.2; 17-70 years); 84.6% were male and 15.4% were smokers. No difference was observed between fixation failure (P = .39) or deep infection (P = .13) with regard to acute vs. delayed reconstruction. No patient demographic or timing of surgery was predictive of fixation failure on regression modeling. Overall, 11 patients underwent revision surgery for loss of reduction and implant failure (n = 5 suture fatigue, n = 2 endobutton escape, n = 2 coracoid stress fracture, and n = 2 deep infection). The EuroQol-5 Dimension (P = .084) and Disabilities of the Arm, Shoulder, and Hand score (P = .062) were comparable for early and delayed groups respectively and below the minimal clinically important difference.
This study found that delayed surgical management of ACJ injuries using a modern device has comparable functional outcomes and is not associated with a higher incidence of fixation failure or major complications.

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Current concepts in management of ACJ injuries

Abstract

Introduction

Section snippets

Classification

Acromioclavicular fixation

Coraco-clavicular fixation

Ligament reconstruction

Conclusion

Declaration of interest

J Shoulder Elb Surg

Arthrosc J Arthrosc R Surg Offic Publ Arthrosc Assoc North Am Int Arthrosc Assoc

Injury

Arthrosc J Arthrosc Relat Surg

Arthrosc J Arthrosc Relat Surg

Epidemiology of acromioclavicular joint injury in young athletes

Am J Sports Med

The Shoulder

Management of chronic unstable acromioclavicular joint injuries

J Orthop Traumatol

Controversies relating to the management of acromioclavicular joint dislocations

The Bone & Joint Journal

Classification of the morphology of the acromioclavicular joint using cadaveric and radiological analysis

Consult Orthop Surg J Bone Joint Surg [Br]

Biomechanical and radiographic analysis of partial coracoclavicular ligament injuries

Am J Sports Med

The treatment of dislocations and fractures of the outer end of the clavicle

Int Clin

A comparative analysis of operative versus nonoperative treatment of grade III acromioclavicular separations

Clin Orthop Relat Res

‘Conservative or surgical treatment of acromioclavicular dislocation. A prospective, controlled, randomized study

J Bone Jt. Surg

Long-term results of conservative treatment for acromioclavicular dislocation

J Bone Jt. Surg

Results of operative and nonoperative treatment of rockwood types III and V acromioclavicular joint dislocation: a prospective, randomized trial with an 18- to 20-year follow-up

Orthop J Sports Med

Functional outcomes of type V acromioclavicular injuries with nonsurgical treatment

J Am Acad Orthop Surg

Sports activity after anatomic acromioclavicular joint stabilisation with flip-button technique

Knee Surg Sports Traumatol Arthrosc: Off J ESSKA

Consistency of long-term outcome of acute rockwood grade III acromioclavicular joint separations after K-wire transfixation

J Trauma Inj Infect Crit Care

‘Long-term results of the surgical treatment of type III acromioclavicular dislocations

J Bone Jt. Surg

Mid-term results after operative treatment of rockwood grade III-V acromioclavicular joint dislocations with an AC-hook-plate

Eur J Med Res BioMed Central

Treatment of tossy III acromioclavicular joint injuries using hook plates and ligament suture

J Orthop Trauma

Clavicular hook plate may induce subacromial shoulder impingement and rotator cuff lesion - dynamic sonographic evaluation

J. Orthop Surgery Res BioMed Central

Arthroscopic fixation of acute acromioclavicular joint disruption with TightRopeTM: outcome and complications after minimum 2 (2–5) years follow-up

J Orthop Surg

Multicenter randomized clinical trial of nonoperative versus operative treatment of acute acromio-clavicular joint dislocation

J Orthop Trauma

Arthroscopic fixation of acute acromioclavicular joint disruption with TightRope^TM: outcome and complications after minimum 2 (2–5) years follow-up