Effect of subacromial erosion shape on rotator cuff and clinical outcomes after hook plate fixation in type 5 acromioclavicular joint dislocations: a retrospective cohort study

Background Surgical fixation using hook plates is widely used in the treatment of acromioclavicular (AC) joint dislocations. The purpose of this study was to evaluate the incidence and shape of subacromial erosions after removal of the hook plate in type 5 AC joint dislocations. Further, we evaluated the effect of the shape of the subacromial erosion on the rotator cuff. Methods We retrospectively reviewed 30 patients who underwent hook plate fixation for type 5 AC joint dislocations at our hospital between December 2010 and December 2018. Patients with a follow-up of at least 1 year were included. Clinical outcomes were assessed using the final follow-up Constant-Murley, Korean Shoulder, and visual analog scores. To ensure that the appropriate reduction was well maintained, the coracoclavicular distances of the injured and contralateral sides were evaluated at the last follow-up. Computed tomography was performed to investigate the presence and shape of the subacromial erosion after hook plate removal at 4 months after surgery. Ultrasonography was performed to investigate the presence of rotator cuff lesions at the last follow-up. Clinical and radiological outcomes were compared between groups divided according to the presence and types of subacromial erosions. Results Subacromial erosion was observed in 60% of patients (18/30): 13, 2, and 3 simple groove, cave, and marginal protrusion types, respectively. Four patients showed reduction loss at the final follow-up. There were no significant differences in clinical and radiological outcomes between the groups with and without subacromial erosion. Moreover, there were no significant differences between groups according to the types of subacromial erosion. There were no rotator cuff lesions, such as partial tears, in the injured shoulders. Conclusions Hook plate fixation may induce subacromial erosions. However, the subacromial erosions caused by the hook plate did not affect the clinical outcomes of type 5 AC joint dislocations. Moreover, regardless of its shape, the subacromial erosion did not affect the clinical outcomes nor cause rotator cuff lesions after plate removal.

Anatomic reconstruction for acromioclavicular joint injuries: a pilot study of a cost-effective new technique

Background: The treatment for acromioclavicular joint injuries (ACJI) ranges from a conservative approach to extensive surgical reconstruction, and the decision on how to manage these injuries depends on the grade of acromioclavicular (AC) joint separation, resources, and skill availability. After a thorough review of the literature, the researchers adopted a simple cost-effective technique of AC joint reconstruction for acute ACJI requiring surgery.Methods: This was a prospective single-center study conducted between April 2017 and April 2018. For patients with acute ACJI more than Rockwood grade 3, the researchers performed open corococlavicular ligament reconstruction using synthetic sutures along with an Endobutton and a figure of 8 button plate. This was followed by AC ligament repair augmenting it with temporary percutaneous AC K-wires. Clinical outcomes were evaluated using the Constant Murley shoulder score. Results: Seventeen patients underwent surgery. The immediate postoperative radiograph showed an anatomical reduction of the AC joint dislocation in all patients. During follow-up, one patient developed subluxation but was asymptomatic. The mean follow-up period was 30 months (range, 24–35 months). The mean Constant score at 24 months was 95. No AC joint degeneration was noted in follow-up X-rays. The follow-up X-rays showed significant infra-clavicular calcification in 11 of the 17 patients, which was an evidence of a healed coracoclavicular ligament post-surgeryConclusions: This study presents a simple cost-effective technique with a short learning curve for anatomic reconstruction of acute ACJI. The preliminary results have been very encouraging.

Acromioclavicular Joint Instability on Cross-Body Adduction View: The Biomechanical Effect of Acromioclavicular and Coracoclavicular Ligaments Sectioning

Background The relationship between acromioclavicular (AC) joint dislocation, corresponding radiological evaluation, and ligament injuries remains controversial. We hypothesized that AC and trapezoid ligament injuries induce AC joint instability, and the clavicle can override the acromion on cross-body adduction view without conoid ligament injury. We aimed to investigate how biomechanically sectioning the AC and coracoclavicular (CC) ligaments contributes to AC joint instability in the cross-body adduction position using fresh-frozen cadaver models. Methods Six fresh-frozen cadaveric shoulders were used in this study, comprising five male and one female specimen, with a mean age of 68.7 (range, 51–87) years). The left side of the trunk and upper limb, and the cervical and thoracic vertebrae and sternum were firmly fixed with an external fixator. The displacement of the distal end of the clavicle relative to the acromion was measured using an electromagnetic tracking device. We simulated AC joint dislocation by sequential resection of AC ligament, AC joint capsule, and CC ligaments in the following order of stages. Stage 0: Intact AC and CC ligaments and acromioclavicular joint capsule; stage 1: Completely sectioned AC ligament and joint disc; stage 2: Sectioned trapezoid ligament; and stage 3: Sectioned conoid ligament. The superior clavicle displacement related to the acromion was measured in the horizontal adduction position, and clavicle overriding on the acromion was assessed radiologically at each stage. Data were analyzed using a one-way analysis of variance and post-hoc tests. Results Superior displacement was 0.3 mm at stage 1, 6.5 mm at stage 2, and 10.7 mm at stage 3. On the cross-body adduction view, there was no distal clavicle overriding at stages 0 and 1, and distal clavicle overriding was observed in five cases (5/6: 83%) at stage 2 and in six cases (6/6: 100%) at stage 3. Conclusion We found that AC and trapezoid ligament sectioning induced AC joint instability and that the clavicle could override the acromion on cross-body adduction view regardless of conoid ligament sectioning. AC and trapezoid ligament injuries may lead to significant AC joint instability, and the distal clavicle may subsequently override the acromion.

Reconstruction of the Coracoclavicular Ligament With Palmaris Longus Tendon and Mersilene Tape for Acromioclavicular Dislocations

Background Acromioclavicular (AC) joint dislocation is common among shoulder injuries, and various surgical methods have been introduced for effective ligament reconstruction. Reconstruction of the coracoclavicular (CC) ligament in the anatomical position using autologous tendons is a recent surgical trend. This study is to report clinical and radiologic results of reconstruction of the CC ligament using an autologous palmaris longus tendon interweaved with Mersilene tape (PLMT) with a minimum 2-year follow-up. Methods This retrospective study analyzed 76 patients (mean age, 43.4 ± 11.2 years) with AC joint dislocation treated by reconstruction of the CC ligament with PLMT, from March 2004 to February 2017. The mean follow-up period was 28 ± 6.7 months (range, 24–66 months). The Visual Analog Scale (VAS) for pain assessment, American Shoulder and Elbow Surgeons rating scale (ASES), and Constant Score (CS) were used to evaluate clinical outcomes at the final follow-up. CC and AC distances were measured using anteroposterior (AP) X-ray preoperatively, 6 weeks postoperatively, and at the final follow-up for radiologic outcomes. Complications were also assessed. Results The mean preoperative VAS, ASES, CS were 5.7 ± 0.7, 77.1 ± 6.2, and 61.5 ± 5.2, respectively. These scores at the last follow-up improved to 2.1 ± 0.5, 90.9 ± 4.3, and 94 ± 7.0, respectively (p = 0.043, p < 0.001, p < 0.001). The mean preoperative CC and AC distances were 16.49 ± 3.73 mm and 13.84 ± 3.98 mm, respectively. They were 7.16 ± 1.22 mm and 3.86 ± 2.34 mm at 6 weeks postoperative, and became 9.29 ± 2.72 mm and 5.30 ± 2.09 mm at the final follow-up. The mean CC and AC distances decreased significantly at the final follow-up (p < 0.001, p < 0.001). Although a slight re-widening of the CC distance occurred in 10 patients (13.1%), most patients regained full range of motion of the affected shoulder at the final follow-up. Conclusion The CC ligament reconstruction with PLMT for the treatment of AC joint dislocation showed good clinical and radiological results. This technique could be a good alternative treatment for AC dislocations.

Sonographic and MRI Presentation of Geyser Sign in Rotator Cuff Tears

Limited cases of rotator cuff tears with acromioclavicular (AC) degeneration in association with cystic swelling or ganglion cyst have been described till date. The “geyser radiographic sign” was originally described by Craig in 1984. Its significance was to document a tear in the articular capsule of the AC joint in the setting of a chronic full-thickness tear of the rotator cuff, which gave the appearance of a geyser arising from the subacromial bursa as radiographic contrast tracked through the AC joint to project superiorly from the shoulder. An 82-year-old male presented with pain on rest in the left shoulder and with difficulty in overhead abduction from last few months. MRI showed near complete full-thickness tear of supraspinatus tendon with retraction of the tendon and reduced bulk of the supraspinatus muscle with associated superior subluxation of humerus with AC arthropathic changes causing ganglion cyst and incidental finding of superior labrum anterior and posterior tear. AC cysts are further divided into Type 1 and Type 2. Repeated aspirations of these masses are not advised, as they often recur and repeated attempts at aspiration may lead to formation of a draining fistula. MRI geyser sign is highly suggestive of a benign process, which suggests underlying rotator cuff pathology.

Coracoid or Clavicle Fractures Associated With Coracoclavicular Ligament Reconstruction

Background: Coracoclavicular (CC) ligament reconstruction is a commonly performed procedure for high-grade acromioclavicular (AC) joint separations. Although distal clavicle and coracoid process fractures represent potential complications, they have been described in only case reports and small case series. Purpose: To identify the incidence and characteristics of clavicle and coracoid fractures after CC ligament reconstruction. Study Design: Case series; Level of evidence, 4. Methods: The US Military Health System Data Repository was queried for patients with a Current Procedural Terminology code for CC ligament repair or reconstruction between October 2013 and March 2020. The electronic health records, including patient characteristics, radiographs, operative reports, and clinical notes, were evaluated for intraoperative or postoperative clavicle or coracoid fractures. Initial operative technique, fracture management, and subsequent clinical outcomes were reviewed for these patients. Results: A total of 896 primary CC ligament repairs or reconstructions were performed during the study period. There were 21 postoperative fractures and 1 intraoperative fracture in 20 patients. Of these fractures, 12 involved the coracoid and 10 involved the clavicle. The overall incidence of fracture was 3.81 fractures per 1000 person-years. In 5 patients who sustained a fracture, bone tunnels were not drilled in the fractured bone during the index procedure. A total of 17 fractures were ultimately treated operatively, whereas 5 fractures had nonoperative management. Of the 16 active-duty servicemembers who sustained intraoperative or postoperative fractures, 11 were unable to return to full military duty after their fracture care. Conclusion: Fracture of the distal clavicle or coracoid process after CC ligament repair or reconstruction is a rare but serious complication that can occur independent of bone tunnels created during the index procedure. Fractures associated with CC ligament procedures occurred at a rate of 2.46 per 100 cases. Most patients were ultimately treated surgically with open reduction and internal fixation or revision CC ligament reconstruction. Although the majority of patients with intraoperative or postoperative fractures regained full range of motion, complications such as anterior shoulder pain, AC joint asymmetry, and activity-related weakness were common sequelae resulting in physical limitations and separation from military service.

Transmural supraspinatus tendon tear caused by suture anchor tip 19-month postacromioclavicular joint stabilisation

Rotator cuff injuries present rarely in paediatric patients due to the tendon strength at this age. There are reports of ruptures caused by either irritation of the lateral clavicle or acromioclavicular (AC) joint in fractures or after usage of hook plates. In this case report, we present a patient with an acute complete supraspinatus rupture caused by a suture anchor tip from a previously performed AC joint stabilisation. After the diagnosis of a new complete supraspinatus, the causative prominent suture anchor was removed, and the tendon subsequently repaired. This case highlights the close anatomic relation of the AC joint and the rotator cuff, which is imperative to adequately address in injuries to this anatomical location.

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean Six-Year Follow-up

Objectives: Over the past decade, there have been advances in arthroscopic-assisted approaches for coracoclavicular (CC) reconstruction with less surgical morbidity and enhanced visualization while also allowing for the treatment of concomitant glenohumeral pathology. Previous studies reporting outcomes using both open and arthroscopic-assisted techniques are limited by short-term follow-up and small patient populations. It also remains unclear how maintenance of reduction and clinical outcomes correlate with one another. The purpose of our study was to report clinical and functional outcomes including return to pre-injury activity level following arthroscopic-assisted CC ligament reconstruction (AA-CCR) and to determine associations between return to pre-injury activity level, radiographic outcomes and patient-reported outcomes scores following AA-CCR. We hypothesized that patients undergoing AA-CCR would have a high rate of return to pre-injury activity level, clinical outcomes would not be associated with RLOR, and that the treatment of concomitant glenohumeral pathology would not adversely affect outcomes. Methods: A retrospective review of prospectively collected data from an institutional registry of all AA-CCR performed from January 2007-January 2016 was performed. Exclusion criteria included revision CCR, open CCR, and patients with less than two-year follow-up. Demographics and patient characteristics including sex, age at index surgery, grade of AC joint injury, duration between injury and index surgery, concomitant glenohumeral pathologies and procedures performed, complications, and subsequent surgeries were recorded. Grade of AC joint injury was determined using the Rockwood classification, and patients indicated for surgery had at least a Type III injury. Time elapsed between injury and index surgery was recorded and classified as acute (0–30 days) or chronic (> 30 days). The arthroscopic-assisted portion of the CC reconstruction has been prevously described and is as follows: The base of the coracoid then exposed either through a subacromial or intraarticular approach. Passing sutures were then placed around the coracoid for later shuttling of the soft tissue graft (allograft semitendinosus/posterior tibialis/anterior tibialis or autograft semitendinosus, according to surgeon preference) and heavy suture, which was used for ancillary fixation. Postoperative radiographs were obtained at approximately two weeks and six months following surgery. The CC distance was measured at final radiographic follow-up and compared to the unaffected contralateral side on an anteroposterior (AP) radiograph. Radiographic loss of reduction (RLOR), was defined as at least a 25% increase in CC distance as measured from the superior cortex of the coracoid process and the undersurface of the clavicle using a radiographic ruler compared to the contralateral side. Clinical assessment at final follow-up included SANE score, and additionally, patients were asked which sports(s) and/or recreational activity(s) they participated in prior to injury. For each sport or recreational activity, they were then specifically asked: “Were you able to return to the same or higher level of (specific sport or activity) as prior to your injury?” Failure of AA-CCR was defined as any one of the following: 1.) Patient underwent revision AC joint stabilization surgery, 2.) Patient was unable to return to the same or higher level of sport(s) and/or recreational activity(s) as prior to injury, 3.) Patient had RLOR as defined above. For comparative analysis, patients were characterized as having one primary mode of treatment failure. Post-hoc analysis was performed considering that patients may have more than one mode of treatment failure. Results: There were 88 patients (89.8% male) with a mean age of 39.6 years (range 18-65) and minimum 2-year follow-up (mean 6.1 years, range 2.1-10.3). Follow-up rate was 67.7%. Mean time from injury to surgery was 7.2±2.4 months, with 70% chronic injuries and 63.6% grade V. Concomitant arthroscopic procedures were performed in 48.9% of cases. Overall, mean SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%, with 8.0% unable to return to activity, 5.7% with RLOR, and 3.4% undergoing revision surgery for failed AA-CCR. Each patient undergoing revision surgery had an identifable traumatic event. All patients with RLOR were able to return to pre-injury activity level. SANE score was lower among patients who were unable to return to activity compared to those with RLOR and compared to non-failures (p=0.0002) (Table 1). Post-hoc analysis considering multiple modes of treatment failure for individual patients demonstrated that SANE score was still significantly lower among those unable to return to pre-injury activity level compared to patients with RLOR and compared to patients considered non-failures (p=0.00003). Ninety three percent of patients who participated in weightlifting, 97% who participated in swimming, and 83% of those who participated in yoga were able to return to their respective activity at the same or higher level as pre-injury at final followup. For all other sporrts, all patients returned to their pre-injury activity level. There were no differences in revision surgery rates, return to activity, or SANE scores according to the specific surgical technique used, Rockwood grade, or if concomitant pathology was treated (Table 2-4). Conclusions: AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to pre-injury activity level. RLOR did not correlate with return to pre-injury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to pre-injury activity level may be a more clinically relevant outcome measure than radiographic maintenance of AC joint reduction. [Table: see text][Table: see text][Table: see text][Table: see text]

Management of Acromioclavicular Osteoarthritis in Rotator Cuff Tears: A Scoping Review

Purpose The treatment of acromioclavicular joint (ACJ) osteoarthritis during shoulder arthroscopy is a discussed topic. The aim of this scoping review is to report the current recommendations regarding the management of this disorder in patients undergoing surgery for rotator cuff tears. Methods A scoping review was performed in Pubmed\Medline and Embase in March 2017, restricted to English language literature. The following keywords were used: (“rotator cuff tear” OR ” rotator cuff” OR “rotator cuff repair”) AND (“acromioclavicular joint arthritis” OR “ac joint arthritis” OR “ac joint” OR “acromioclavicular joint”). Inclusion criteria were randomized controlled trials, prospective cohort studies, retrospective trials, and therapeutic case series. Exclusion criteria were reviews, meta-analyses, and expert opinions. Results Two retrospective studies and three randomized controlled trials were identified. Clinical studies reported results of 443 shoulders, with an average age of 60.48 years and a mean follow-up of 31.7 months. Many differences were found regarding the design of the studies, patient's selection, surgical procedures, and instrumental and clinical evaluations. No statistically significant differences were found in clinical outcome scores between patients that underwent rotator cuff repair in association with distal clavicular resection and patients with isolated rotator cuff repair. Conclusion Results of this scoping review underline a lack of evidence-based recommendations about the management of ACJ osteoarthritis in association with arthroscopic rotator cuff repair. Surgical procedures such as distal clavicle resection (DCR) should be performed carefully in this cohort of patients. More prospective randomized studies are needed to reach a consensus about the correct surgical approach to DCR in patients with signs of ACJ osteoarthritis and rotator cuff tears. Level of Evidence Level III.

Acute high-grade acromioclavicular joint dislocation patients treated with titanium cable insertion under a homemade guider

Backgrounds To describe a new technique for implanting a double-bundle titanium cable to treat acromioclavicular (AC) joint dislocation via the new guider, and evaluate clinic outcomes. Methods A retrospective study of patients treated for acute high-grade acromioclavicular joint dislocation from June 2016 to January 2020 in our trauma center, twenty patients with AC joint dislocation were managed with double-bundle titanium cable. It includes the following steps: (1) Put the guider under the coracoid close to the cortical; (2) drill proximal clavicle; (3) place the titanium cable; (4) perforate distal clavicle, (5) reset the acromioclavicular joint and lock titanium cable; and (6) suture the acromioclavicular ligament. An independent reviewer conducted functional testing of these patients, including the use of coracoclavicular distance (CCD), visual analog scale (VAS) scores, and Constant–Murley scores (CMS). Results All patients are presented following at a median duration of 15 months (12-24months) after the surgery. All patients based on X-ray evaluation and clinic evaluation. The median CCD was 7.5 (6–14) mm, the VAS score was 0.55 (0-2), the CMS score was 95.5 (92-99). One patient had subluxation again at the final follow-up based on X-ray examination. Conclusions This study demonstrates that the AC joint fixation anatomically with double-bundle titanium, acquired excellent outcomes in terms of the recovery of shoulder joint function and radiographic outcomes. It has a low complication rate and need not remove the hardware.