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Complications of the acromioclavicular joint injuries can occur as a result of the injury itself, conservative management, or surgical treatment. Fortunately, the majority of acromioclavicular surgeries utilizing modern techniques and instrumentation result in successful outcomes. However, clinical failures do occur with frequency. The ability to i...
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Context 1
... of AC injuries is based on the extent of in- volvement of the AC and coracoclavicular (CC) ligaments (Table 1) [2]. An understanding of this classification system will assist in guiding patient expectations, discussion of avail- able treatment options, and formulating a proper surgical plan to address the associated injuries. ...
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Introduction:
Shoulder pain is common in persons with chronic spinal cord injury (SCI), with a prevalence reported as high as 70%. Current treatment of shoulder pain includes conservative measures such as physical therapy, pain medications, patient education, injections, and assistive devices. When conservative treatments fail, shoulder surgery is...
Citations
... ACJ dislocations are common in general practice and athletic activities, particularly among the young and active population, representing approximately 9 to 12% of shoulder girdle injuries and approximately 8% of all body dislocations [1][2][3]. ...
... ACJ dislocations have several classifications [1,2]. However, the most widely used is the one proposed by Rockwood et al., which is based on the increasing severity of the subsequent injury of stabilizing structures of the ACJ [3]. Understanding this classification system will assist in guiding patient expectations, discussing available treatment options, and helping in planning surgery [21]. ...
... Vertical instability is relatively easy to assess on radiographs, but the posterior displacement of the clavicle (horizontal stability) is sometimes very subtle and should be considered because it can lead to chronic pain and disability and must be corrected if surgical treatment is performed [7,22]. For these reasons, some authors recommend an additional projection known as the crossbody adduction view (Basmania) for the assessment of the degree of clavicular overlap with the acromion [3,9]. Overlapping of the clavicle is used by ISAKOS to subclassify Rockwood type III ACJ dislocation into type IIIA (when there is no overlapping) and type IIIB (when there is overlapping), which has an impact on the treatment (see ACJ dislocation treatment) [4] (Fig. 10). ...
Acromioclavicular joint (ACJ) dislocations are a common cause of pain in patients of any age. Athletes who participate in contact sports, such as hockey, football, rugby, and soccer, are particularly susceptible to such injuries. The ACJ has an important role in the function of the upper limb, and its complexity of movement makes it susceptible to acute injuries and chronic dysfunction with debilitating effects that must be treated appropriately and promptly to preserve function. Recently, ACJ has received increasing attention due to the development of new surgical techniques for the restoration of normal function and stability. There is some agreement about the treatment of ACJ dislocations, but controversy remains about the treatment of Rockwood grade III dislocations, and a new approach to these injuries is suggested by ISAKOS. Overall, the paper summarizes new concepts in the anatomy of the ACJ and reviews the utility of imaging methods in ACJ dislocations as well as their treatment and complications.
... Some surgeons commented that they leave it to patients to decide. This shows the importance of informed patient decisionmaking, thus avoiding unwanted surgery and unwanted complications [27,28] with disruptions to the patients' daily living [25]. The poor readability scores for the webpages reviewed make the information inaccessible to most patients leading to disruption in the shared decisionmaking process. ...
Currently, patients use the Internet for health information relating to surgery. The aim of this study is to assess the readability and quality of online health information relating to acromioclavicular joint reconstruction. We hypothesise that the information will be of poor quality and be too difficult to read for the average patient. The top 50 results from Google, Bing, and Yahoo (MeSH “acromioclavicular joint reconstruction”, “ac joint reconstruction”) were used for analysis. Readability was assessed using three scores (Gunning FOG (GF), Flesch–Kincaid Grade (FKG), and Flesch Reading Ease (FRE)); these scores were generated using an online calculator (www.readable.com). Quality was assessed using a HONcode Google Toolbar extension and JAMA benchmark criteria. One hundred sixteen webpages were subject to analysis. The mean GF was 12.1 ± 2.9. The mean FKG was 10.6 ± 2.15. The mean FRE was 38.9 ± 13.3. FRE score found no webpage pitched at the 6th grade level, and only 4 (3.4%) and 2 (1.7%) of the webpages were pitched at this level according to the GF and FKG scores, respectively. The mean JAMA score was 1.9 ± 1.5. Only 10 webpages had HONcode certification. The quality of online patient information pertaining to acromioclavicular joint reconstruction is of poor quality and is too difficult to read. Physicians and health information providers should conform to health literacy standards. Health information providers should meet the minimum standards of verified assessment tools.
... Many of the methods focus on vertical instability (disruption of the CC ligaments). Horizontal instability (AC ligament disruption) has received less attention [1,9,10]. There is currently no gold standard surgical treatment for any type of AC injury, especially for horizontal ACJ instability [4,8,10,11]. ...
... Horizontal instability (AC ligament disruption) has received less attention [1,9,10]. There is currently no gold standard surgical treatment for any type of AC injury, especially for horizontal ACJ instability [4,8,10,11]. This study examined the effects of two Ethibond suture techniques, the loop technique and the two holes in the clavicle technique, on the horizontal stability of the ACJ following its complete dislocation. ...
Background:
Most acromioclavicular joint (ACJ) injuries are caused by direct trauma to the shoulders, and various methods and techniques are used to treat them; however, none of the options can be considered the gold standard. This study examines the horizontal stability of the ACJ after a complete dislocation was repaired using one of two Ethibond suture techniques, the loop technique and the two holes in the clavicle technique.
Methods:
In this single-blind, randomized clinical trial, 104 patients diagnosed with complete ACJ dislocation type V were treated using Ethibond sutures with either the loop technique or the two holes in the clavicle technique. Horizontal changes in the ACJ were radiographically assessed in the lateral axial view, and shoulder function was evaluated by the Constant (CS) and Taft (TS) scores at intervals of 3, 6, and 12 months after surgery.
Results:
The horizontal stability of the ACJ was better with the two-hole technique than the loop technique at all measurement times. CS and TS changes showed a significant upward trend over time with both techniques. The mean CS and TS at the final visit were 95.2 and 11.6 with the loop technique and 94 and 11.9 with the two-hole technique, respectively. The incidence of superficial infections caused by the subcutaneous pins was the same in the two groups.
Conclusions:
Due to the improved ACJ stability with the two-hole technique, it appears to be a more suitable option than the loop technique for AC joint reduction.
... Known complications include loss of reduction, fracture, graft failure, and hardware failure, among others [3]. We present a novel technique in looping the graft around the clavicle and coracoid and secure it using a hook plate. ...
... Coracoid fractures secondary to AC joint reconstructive reconstruction techniques still remain a complication [3]. Techniques that include intra-osseous buttons, screws, and suture tunnels have all been reported to cause intra-operative fractures [4,5]. ...
There are many documented techniques for the surgical treatment of a chronic acromioclavicular (AC) joint reconstruction, but unfortunately, there is no gold standard. Treatment options include hook plates, allograft reconstruction, and suture fixation, among many others.
This technique is an innovative method for looping the allograft around the coracoid and clavicle and using the hook plate for fixation. This avoids any drilling within the clavicle or coracoid, therefore decreasing the risk of fracture and ensuring the reduction of the AC joint.
... Multiple techniques have been described, including joint pinning [5], hook plates [6], CC cerclages [7], endobuttons [8], ligament transfers [9], and repair of the native AC and CC ligaments [10]. Despite the availability of techniques and focus in the literature, the risk of significant complication still exists [11][12][13]. ...
Purpose:
The optimal surgical technique for unstable acromioclavicular (AC) and coracoclavicular (CC) joint injuries has not yet been established. The biomechanical and radiographic effect of the LockDown device, a synthetic ligament for AC joint reconstruction, was evaluated to assess the optimal surgical technique for unstable AC and CC joint injuries. It was hypothesized that the LockDown device would restore AC joint kinematics and radiographic stability to near native values.
Methods:
Three fresh frozen cadaveric torsos (6 shoulders) modelled CC joint motion in their "native," "severed," and "reconstructed" states. The effects of stressed and unstressed native, severed, and reconstructed conditions on AC separation and CC distances in anteroposterior, mediolateral, and inferosuperior directions during shoulder abduction, flexion, and scaption were assessed. The analysis of variance (p, 0.05) was used to compare CC distance and peak AC distance in anteroposterior, mediolateral, and inferosuperior directions during shoulder flexion, abduction, and scaption measurements among native, severed, and reconstructed states with unstressed and stressed Zanca radiographic views.
Results:
From radiographic analyses, the CC distance was significantly greater (p=0.001) across the surgical state in stressed versus unstressed views. Mean difference between stressed and unstressed views was 1.8 mm in native state, 4.1 mm in severed state, and 0.9 mm in reconstructed state. The CC distance was significantly greater in the "severed" state (10.4 mm unstressed; 14.5 mm stressed) compared to the "native" state (p=0.016) (6.5 mm unstressed; 8.3 mm stressed) and compared to the "reconstructed" state (p=0.005) (3.1 mm unstressed; 4.0 mm stressed) and significantly less (p=0.008) in the "reconstructed" state compared to the "native" state. CC distances decreased from native to reconstructed, an average of 3.3 mm for unstressed and 4.3 mm for stressed. On average, peak AC joint separation distance in anteroposterior, mediolateral, and inferosuperior directions during shoulder-abduction, flexion, and scaption was shown to be restored to 11.5 mm of native values after reconstruction with LockDown device.
Conclusion:
Reconstruction of AC joint with LockDown synthetic ligament restores motion of clavicle and acromion to near native values, thereby decreasing scapular dyskinesis and enhancing AC joint stability.
... However, wire migration ( Fig. 26) into the pleural space, spinal canal, and adjacent vascular structures is a potential complication that dissuades prevalent use [70]. If pins are used for stabilization, their position should be checked with frequent radiographs, and they should be removed after initial healing [71]. Common complication following AC joint reconstruction is loss of reduction (Fig. 27), occurring in 15-80% of patients [71]. ...
... If pins are used for stabilization, their position should be checked with frequent radiographs, and they should be removed after initial healing [71]. Common complication following AC joint reconstruction is loss of reduction (Fig. 27), occurring in 15-80% of patients [71]. Report checklist 1. ...
... Group 2 clavicular fractures that involve the CC ligaments carry a worse prognosis [20,71,75]. Any radiographic evidence of AC joint or ligamentous injury should also be emphasized and accompanied by a recommendation for additional evaluation with MRI or CT since delays in diagnosis may translate into an under appreciation of the injury's complexity or severity. ...
Imaging plays a key role in the assessment and management of traumatic shoulder injuries, and it is important to understand how the imaging details help guide orthopedic surgeons in determining the role for surgical treatment. Imaging is also crucial in preoperative planning, the longitudinal assessment after surgery and the identification of complications after treatment. This review discusses the mechanisms of injury, key imaging findings, therapeutic options and associated complications for the most common shoulder injuries, tailored to the orthopedic surgeon’s perspective.
... For this reason, it is very important to detect both vertical and horizontal instability using precise, reliable, and reproducible methods. 7,10,22 Radiography is routinely used as an imaging tool in the assessment of AC joint injuries because the equipment is widely available and provides convincing results. 3,17,19 However, in the literature, there is no consensus regarding the standard view for the radiographic evaluation of acute horizontal instability of the AC joint. ...
Background
Operative treatment is suggested for unstable type 3 acromioclavicular (AC) joint injuries; however, there is no clear consensus regarding the definition of an unstable type 3 injury. We propose a new radiographic method, the “Chiang Mai lean forward” view, to verify horizontal displacement in an unstable AC joint injury.
Hypothesis
A radiograph taken with the torso leaning forward would allow the detection of a higher proportion of AC joint injuries.
Study Design
Descriptive laboratory study.
Methods
A total of 20 shoulders from 10 fresh whole-body cadaveric specimens (mean age, 68.8 years) were tested at 3 different torso leaning angles (30°, 45°, and 60°) to determine the best position for projecting the x-ray beam. The shoulders were dissected sequentially starting with the AC ligament (stage 1), then additional sectioning of the partial coracoclavicular (CC) ligament with either the trapezoid ligament cut first (stage 2A) or the conoid ligament cut first (stage 2B), and finally complete sectioning of the CC ligament (stage 3). Radiography was performed after each stage to evaluate the degree of displacement of the anterior border of the acromion relative to the anterior border of the clavicle. Paired t tests were used to compare the degree of displacement at each stage to that of the shoulder before cutting.
Results
Leaning at an angle of 30° provided better visualization of the AC joint in the “Chiang Mai lean forward” view. Compared with the intact condition, complete isolated cutting of the AC ligament produced 5.21 mm of horizontal displacement of the AC joint ( P < .0001), complete tearing of the AC ligament and partial cutting of the CC ligament resulted in a displacement of <12 mm (7.91 mm at stage 2A [ P = .0003] and 8.10 mm at stage 2B [ P = .0013]), and complete tearing of both the AC and the CC ligaments resulted in a displacement of 26.37 mm ( P < .0001).
Conclusion
The “Chiang Mai lean forward” radiographic view is a potentially useful tool for determining the degree of the injury and the stability of the AC joint.
... The overall infection rate is similar to reported rates which range from 0 to 9 %. 23 Postoperative clavicle fracture is a described complication after anatomic coracoclavicular (CC) ligament reconstruction. Turman et al. described 3 cases of postoperative clavicle fractures through two bone tunnels created for CC ligament reconstruction. ...
Introduction: Acromioclavicular joint dislocations account for approximately 12% of injuries to the shoulder girdle. Reconstruction of these dislocations is advised and various authors have described different techniques. The modern approach has emphasized anatomic reconstruction using semitendinosus autograft. Methods: Adults with chronic acromioclavicular joint dislocation presenting to our hospital underwent reconstruction of the joint. A standard protocol of surgery and post-operative rehabilitation was followed. The functional outcome was assessed using the Constant-Murley shoulder score after six months. Results: A total of twenty-one patients were evaluated. The functional outcome was assessed at 24 weeks using the Constant-Murley score. Nineteen patients (90.4%) had a very good outcome, one patient had a good outcome whereas one had a fair outcome. Conclusion: The anatomic reconstruction of the acromioclavicular joint using semitendinosus graft results in very good outcomes with few complications.
... Despite its popularity, the failure of two-tunnel reconstruction is still a significant problem (Kocadal et al., 2018). Although non-anatomic techniques (which may consider the use of a single tunnel) have been described, the current literature recommends that two clavicular tunnels should be positioned at the anatomic insertions of the CC ligaments with a minimum bone bridge of 15 mm using the tunnel's center point for reference in order to reproduce the anatomy and reduce the risk of failure and clavicular fracture (Barth et al., 2015;Ma et al., 2015;Milewski et al., 2012). However, there is limited experimental or clinical evidence to support this premise. ...
... Anatomic stabilization techniques for AC joint injuries require two clavicular tunnels to restore the function of both CC ligaments. It has been recommended that a bone bridge of at least 15 mm is required to reduce the risk of failure and clavicular fracture (Barth et al., 2015;Ma et al., 2015;Milewski et al., 2012). However, to our knowledge, there is no clinical or experimental evidence to support this premise. ...
... Following a thorough literature review, there remains ambiguity regarding the measurement of bone bridge distance and placement of clavicular tunnels. Most authors use the center of their tunnels, as originally described by Mazzoca (Mazzocca et al., 2004), to measure clavicular tunnel distance rather than the bone bridge length between them (Barth et al., 2015;Carofino and Mazzocca, 2010;Ma et al., 2015;Milewski et al., 2012). This is a critical point that needs to be clarified to minimize the risk of a clavicle fracture. ...
Background
This study aims to evaluate the relation between coracoclavicular resistance to failure and the distance between clavicular tunnels. The hypothesis is that a greater clavicular bone bridge between tunnels achieves a stronger coracoclavicular fixation.
Methods
Descriptive Laboratory Study. Thirty-six (36) coracoclavicular models were constructed utilizing porcine metatarsals. Coracoclavicular stabilizations were performed using a subcoracoid loop fixation configuration through two clavicular tunnels, tied at the clavicle's superior cortex using a locking knot. Models were randomly assigned to 1 of 3 experimental groups of variable bone bridge length between clavicular tunnels: 5 mm, 10 mm, and 15 mm. Each group had 12 models. Fixation resistance was assessed through the ultimate failure point under an axial load to failure trial. Failure patterns were documented. A one-way ANOVA test was used, and a Tukey post hoc as needed (P < 0.05).
Findings
Mean strength per bone bridge length: 5 mm = 312 N (Range: 182-442 N); 10 mm = 430 N (Range: 368-595 N); 15 mm = 595 N (Range: 441-978 N). The 15 mm group had a significantly higher ultimate failure point than the other two groups: 5 mm (P < 0.001) and 10 mm (P < 0.001). All fixations systematically failed by a superior cortex clavicle fracture at the midpoint between tunnels.
Interpretation
A direct relationship between bone bridge length and coracoclavicular resistance to failure was demonstrated, being the 15 mm length a significantly higher strength construct in a tied loop model.
... Loss of reduction alignment after AC joint fixation with CC stabilization is one of the most common complications of this procedure, 20,29 but it may not be correlated with worse outcomes, as defined by many studies. 1,7,18,24,25 One study reported a 21% to 50% incidence of loss of reduction alignment with this procedure. The authors of that study hypothesized that the problem resulted from slippage of the suspension sutures and/or the postoperative clavicular tunnel angle leading to tunnel widening. ...
Background
The postoperative failure rate of acromioclavicular (AC) joint fixation using the coracoclavicular (CC) stabilization technique is high. Studies have reported that compared with normal intraoperative anatomic reduction, intraoperative overreduction of the AC joint is more successful in achieving a satisfactory anatomic radiographic outcome at 1- to 2-year follow-up.
Purpose
To evaluate the functional and radiographic outcomes and complications in patients with acute AC joint injury who underwent combined CC stabilization and AC capsular repair in which the CC distance was intraoperatively decreased to 50% of the unaffected side.
Study Design
Case series; Level of evidence, 4.
Methods
In this retrospective study, we collected and analyzed the data of patients with an acute AC joint injury (Rockwood type 5) who underwent combined CC stabilization and AC capsular repair during which the CC distance was decreased 50% compared with the unaffected side. At 2-year follow-up, we evaluated functional outcomes (American Shoulder and Elbow Surgeons [ASES] score), radiographic outcomes (alignment of the AC joint in the vertical and horizontal planes, tunnel widening), and complications (infection, clavicular fracture).
Results
The study included 20 patients with a mean ± SD age of 42.20 ± 10.10 years. The mean follow-up period was 33.75 ± 11.50 months. At the 2-year follow-up, the mean ASES score was 95.13 ± 5.61. The overreduction alignment, anatomic alignment, and loss reduction alignment rates were 0% (0/20 patients), 95% (19/20 patients), and 5% (1/ 20 patients), respectively. No statistically significant difference was found in the mean CC distance between the affected and unaffected sides on radiographic evaluation. The mean medial clavicular tunnel width and lateral clavicular tunnel width were 5.03 ± 0.68 mm and 4.47 ± 0.67 mm, respectively. None of the patients experienced fractures or infections.
Conclusion
Excellent functional and radiographic outcomes and no complications were seen at 2-year follow-up in patients with acute AC joint injury who underwent combined CC stabilization and AC capsular repair with the CC distance intraoperatively decreased to 50% of the unaffected side.
