Surgical treatment of acute acromioclavicular joint dislocations: hook plate versus minimally invasive reconstruction

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1 DOI /s SHOULDER Surgical treatment of acute acromioclavicular joint dislocations: hook plate versus minimally invasive reconstruction S. Metzlaff S. Rosslenbroich P. H. Forkel B. Schliemann H. Arshad M. Raschke W. Petersen Received: 1 October 2013 / Accepted: 28 August 2014 European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014 Abstract Purpose This study was performed to compare the clinical results of a minimally invasive technique for acute acromioclavicular (AC) joint dislocation repair with the traditional hook plate fixation. Methods Forty-four patients with an acute (within 2 weeks after trauma) complete AC joint separation (35 male, nine female; median age 36.2 years, range 18 56) underwent surgical repair with either a minimally invasive AC joint repair or a conventional hook plate. Functional outcome was evaluated using the Constant-Murley Score (CMS), the TAFT score and the AC joint instability score (ACJI). Radiographic evaluation was performed with bilateral anterior posterior (a.p.) stress and Alexander views. Results All patients were available after a median follow-up of 32 months (range 24 51). There were no significant differences in the mean CMS, Taft score and the ACJI between the two groups. The radiological assessment revealed no significant difference in the coracoclavicular distance. In both groups, a slight loss of reduction was observed. Periarticular ossification was seen in 11 patients of the minimally invasive AC joint repair and eight patients of the hook plate group but this did not affect the final outcome. Hook plates were removed after a median interval of 11.9 weeks (range 10 13). S. Metzlaff (*) P. H. Forkel W. Petersen Department of Orthopaedic and Trauma Surgery, Martin Luther Hospital, Grunewald, Berlin, Germany sebastian.metzlaff@web.de S. Rosslenbroich B. Schliemann M. Raschke Department of Orthopaedic and Trauma Surgery, University Hospital Münster, Münster, Germany H. Arshad Norfolk and Norwich University Hospital, Norwich, UK Conclusion Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation. However, in the hook plate group a second operation is mandatory for plate removal. Level of evidence III. Keywords Acromioclavicular joint dislocation Rockwood classification Minimally invasive AC joint repair Coracoclavicular cerclage MINAR Introduction Treatment of complete Acromioclavicular (AC) joint dislocation remains controversial and ranges from non-operative treatment for Rockwood type I III injuries to an extensive surgical reconstruction using tendon grafts in chronic cases. High-grade injuries (Rockwood type IV, V and VI) of the AC joint or type III injuries in athletes are considered to be indications for surgery [2, 15]. AC or coracoclavicular (CC) augmentations have been used successfully to treat these injuries [6 9, 12, 15, 16, 18, 21, 23, 25, 27 29, 34]. Furthermore, wires and threaded pins are frequently used for temporary fixation of the AC joint. However, serious concerns still exist regarding pin migration or breakage, pin-site infection, fixation failure, and recurrent instability after pin removal [11, 17, 21]. Another well-established method for AC joint reconstruction is the hook plate (HP, Fig. 1) [6, 8, 15, 25]. This plate is fixed to the clavicle by cortical screws while reduction of the clavicle is achieved by a hook placed below the acromion. Although good results have been published, there are known disadvantages with this technique including a mandatory second operation in order to remove the plate.

2 assisted manner and biomechanical clinical studies report a high fixation strength and good-to-excellent functional results [20, 23, 27, 28, 31, 34]. However, comparative studies to HP fixation are lacking. The aim of the present study was therefore to evaluate clinical and radiographic results of patients treated with either HP fixation or minimally invasive AC joint repair (MINAR) for an acute AC joint dislocation. Our hypothesis was that minimally invasive repair leads to equal functional and radiographic results when compared to HP fixation. Materials and methods Fig. 1 Post-operative result after treatment with the hook plate at 12 weeks post-operatively Fig. 2 Post-operative result after treatment with the MINAR technique at 25 months post-operatively The use of cerclages for CC augmentation is an alternative to pin fixation or HP procedures that does not require implant removal [7, 12, 18]. The main problems associated with CC loop augmentations are the highly invasive approach to the coracoid base and an anterior subluxation of the clavicle causing a mal-reduction of the acromioclavicular joint in the post-operative course [12]. Furthermore, a sawing effect of the synthetic materials due to clavicle rotation has been described [12]. The highly invasive approach is associated with increased post-operative morbidity [34]. To overcome these disadvantages minimally invasive techniques for CC augmentation using flip buttons have been developed (Fig. 2) [27, 28, 31, 34]. Operations can be performed in a minimally invasive or arthroscopically Between February 2007 and June 2011, 44 patients (35 male, 9 female; median age 37.6 years, range 18 56) underwent surgical reconstruction for an acute AC joint dislocation type III V according to Rockwood s classification [24]. Twenty patients were treated with HP fixation, and 24 patients underwent minimally invasive AC joint reconstruction (MINAR, Karl Storz, Tuttlingen, Germany). All patients were operated within 2 weeks after trauma. Operations in the MINAR group were performed by two surgeons (one resident and one consultant). Patients in the hook plate group were treated by six different surgeons (four residents and two consultants). Inclusion criteria: acute (<2 weeks after trauma) high-grade AC joint injury Rockwood type III (manual/overhead workers or physically active young adults) type IV and type V surgical treatment with either HP fixation or MINAR patients age >18 years Exclusion criteria: chronic AC joint separations (>3 weeks after trauma) previous AC joint injuries type III innury in elderly patients (>65 years) concomitant lesions to the affected arm Initial radiologic examination consisted of three views: anteroposterior (a.p.) view with 10 cranial tilt of the beam, a true axillary and a.p. stress radiography of both AC joints with a load of 10 kg applied to the forearm. Vertical displacement of the clavicle was classified as type V injury in 20 cases (10 HP, 10 MINAR) and as type III injury in 24 cases (10 HP, 14 MINAR). In 12 cases (6 HP, 6 MINAR), an additional horizontal displacement was documented, representing a type IV injury).

3 Surgical technique of open reduction and HP fixation Under general anaesthesia, the patient was placed in the beach-chair position and the entire upper extremity was prepared and draped in a manner to allow full and unrestricted arm positioning during the procedure. One dose of a second-generation cephalosporin was administered 1 h before incision as infection prophylaxis. A 5-cm skin incision was performed along the distal clavicle towards the acromion. After anatomic reduction of the AC joint, a Dreithaler plate (AAP, Berlin, Germany) was inserted under the acromion. The plate was then fixed to the lateral clavicle with three cortical screws. Plate position and reduction were controlled fluoroscopically. No effort was made to directly repair the disrupted AC or CC ligaments. After wound closure, a 15 abduction brace (Omo immobil, Otto Bock, Duderstadt, Germany) was applied. Surgical technique of the MINAR The operative set-up was the same as for HP fixation. The coracoid process was exposed by a 3-cm-long skin incision. A guide wire was drilled through the coracoid process with the use of a specific aiming device. Then, the guide wire was overdrilled with a 4.5-mm cannulated drill. Two flip buttons (FlippTack, Karl Storz, Tuttlingen, Germany) were then assembled with a braided non-biodegradable 1.0-mm suture (Ethibond, Ethicon, Cincinnati, OH, USA). One of the buttons was then guided through the coracoid drill hole using a specific button pusher and flipped to a horizontal position. The other anchor was shuttled through clavicle drill hole. After anatomic reduction, five surgical knots were tied to secure the reconstruction. Reduction was controlled fluoroscopically. Again, no effort was made to directly repair the disrupted CC or CC ligaments. The shoulder was also immobilized in a 15 abduction brace. Rehabilitation The rehabilitation protocol was the same in both treatment groups. The abduction brace was applied for 4 weeks. The patient was discharged 1 2 days after surgery and guided to perform passive shoulder motion by means of pendulum exercises. Actively assisted shoulder exercises were initiated 2 3 weeks later, but the patient was allowed forward flexion up to 90 only, external rotation up to 30 and internal rotation only to the chest wall. Forward flexion was limited to 90 to minimise clavicular rotation. Range of motion was advanced 6 weeks after surgery until full active range of motion was regained. A strengthening programme was started thereafter and included isometric exercises with progression to resistive exercises. In the hook plate group, the patient was advised that the implant should be removed weeks after surgery. Heavy lifting or any other activity that would result in significant downward traction on the upper extremity was avoided for 3 4 months post-operatively. Strenuous use of the arm, including significant athletic activity, was not advised until 4 months post-operatively. Follow up examination All 44 patients were available for clinical and radiologic assessment after a median follow-up period of 32 months (range 24 51). Involvement in a bicycle accident was the most common injury (24 patients), followed by sports injuries (14 patients), simple falls (six patients), and falls from height (two patients). The functional outcome was assessed at the final followup with the Constant-Murley Score (CMS) [5], the Taft score [31] and the AC joint instability score (ACJI) [28]. The CMS was developed for the evaluation of shoulder function with subjective and objective components. The Taft score contains subjective, objective and radiographic criteria. The (ACJI) described by Scheibel also includes subjective and radiographic criteria [28]. Radiographic evaluation consisted of a.p. (Zanca) view, bilateral Alexander view and a.p. stress view with a load of 10 kg weight to both forearms. Reduction of the AC joint and presence of degenerative changes were evaluated in a.p. and Alexander views. The CC distance was measured on a.p. stress radiographs. Ossifications within the CC ligaments were classified as absent, minor or major; minor ossifications were represented by spots or small ossicles located in the CC ligaments, whereas major ossifications were considered as almost complete bridging between the clavicle and the coracoid process. Ultrasound was used to determine the AC distance (Fig. 3). This retrospective comparative study was approved by the local institutional review board. All patients gave their written informed consent for the use of their data in this report. Statistical analysis A power analysis has shown that a group size of 20 patients has an 80 % power to detect a group difference. Statistical significance of the differences in the scores and radiological measurements between the two groups was tested with the Wilcoxon test. Differences were considered significant with P < 0.05.

4 Fig. 3 Measurement of the AC distance in ultrasound at follow-up Results Functional outcome The mean CMS was 92.8 points (±3.8) in the HP group and 93.6 points (±3.4) in the MINAR group (Fig. 4). This difference was not statistically significant (n.s.). The mean Taft score was 10.5 points (±1.2) in the HP group and 10.9 points (±0.9) in the MINAR group (Fig. 5). This difference was also not statistically significant (n.s.). The ACJI score averaged 80.8 points (±5.7) in the HP group and 78.1 points (±10.1) in the MINAR group (Fig. 6). Again this difference was not statistically significant (n.s.). All athletes except one in the HP group (not caused by the injury) returned to the same level of athletic performance at a period of 6 months after the procedure. None of the other patients modified their occupations because of the injury. In one case, a loss of reduction was recognised in the MINAR group due to loosening of the clavicular button. Revision was performed 2 days after primary surgery. Wound healing was without any complication in both groups and no post-operative infection occured. In all patients of the HP group, the implant was removed after a median interval of 11.9 weeks (range 10 13) postoperatively. No planned secondary surgical intervention was necessary in the MINAR group. The mean duration of surgery was 36.2 min (±15.3) in the MINAR group and 45.6 (±12.7) minutes in the HP group. Radiological measurements In the MINAR group, no coracoid fractures occurred. In one case, loss of reduction due to implant loosening was Fig. 4 Constant score of the hook plate and MINAR group TAFT Score TAFT Score mean 10.5 mean 10.9 Method HK MINAR Fig. 5 Taft score of the hook plate and MINAR group observed. In the hook plate group, no implant loosening or acromial osteolysis was seen. The mean final CC distance was 14.1 mm (range mm) in the HP group in comparison with 13.2 mm (range mm) in the MINAR group. Slight loss of reduction (<50 % of the width of the clavicle) was noted in two patients of both groups with no impact on their functional outcome. Radiographic signs of posterior instability were noted in five cases of the HP group compared to three cases in the MINAR group. Patients with evidence of posterior instability had inferior results in the Taft score and the ACJI (P < 0.05).

5 Radiologic evidence of posttraumatic AC joint degeneration was not detected. The incidence of ossification along the course of the CC ligaments was higher in the MINAR group compared to the HP group (11 vs. 8 patients). Discussion ACJI Score mean 80.8 mean 78.1 Fig. 6 Scheibel AC joint instability score of the hook plate and MINAR group The most important finding of the present study is that good-to-excellent functional results can be achieved with both HP fixation and MINAR in patients treated for an AC joint dislocation type III V. No significant differences in the clinical scores as well as in the radiological outcome could be detected. In the MINAR group, the incidence of minor ossifications was higher, but this did not influence the clinical result. However, a second operation was required in all patients of the HP group for implant removal. These results are in accordance with previous reports. Di Franceco et al. [6] published a case series of 42 patients who underwent AC joint repair with the Dreithaler hook plate. An acceptable joint alignment was achieved in all the patients after surgery. Kienast et al. concluded that clavicle hook plate is a convenient device for the surgical treatment of Rockwood type III V dislocations, leading to good mid-term results with a low overall complication rate [15]. The average CMS in their study was 92.4 points. Most authors agree that despite the encouraging clinical results, the obvious disadvantage of HP fixation is the need for implant removal [6, 8, 15, 25, 29, 33]. In addition, acromial osteolysis is a known complication of this technique [8]. In our study, no acromial osteolysis was observed. A cause for this finding might be that all plates were removed after weeks after surgery. An alternative technique to the HP fixation is the CC augmentation with wires or sutures [18]. Greiner et al. [12] examined 50 patients with a follow-up of 70 months. Clinical scores were good to excellent with a mean CMS of 91.7 points. Comparable results were described by Dimankopoulos et al. [7]. In this study, the mean CMS was 93.5 points. Two cases with slight loss of reduction (<50 % of the width of the clavicle) were detected. The main problems in the clinical routine of CC sling augmentations are the highly invasive preparation of the coracoid basis and an anterior subluxation of the clavicle causing a mal-reduction of the AC joint [1, 10, 13, 19, 22]. Significant anterior displacement of the clavicle in clinical trials was caused by a simple CC loop [3, 11]. Furthermore, the synthetic materials used for CC cerclages have been found to have a sawing effect due to rotational motion of the clavicle with damage of the lateral clavicle and the coracoid process [11, 14]. To overcome these disadvantages, minimally invasive or arthroscopically assisted CC repairs were developed [26, 27, 30 32, 34]. The main principle of these techniques is to approximate the stubs of the torn CC ligament with the use of a flip buttons assembled with heavy sutures in a liftingblock fashion. Anterior subluxation of the clavicle can be prevented by anatomical placement of the device along the course of the CC ligaments [4]. While the MINAR is usually performed in a minimally invasive manner, CC augmentation with the so-called TightRope device (Arthrex, Naples, Florida, USA) is an all-arthroscopic procedure. Good-to-excellent clinical results have been reported despite the occurrence of partial loss of reduction in some cases [20, 27, 28, 31]. For example, Scheibel et al. evaluated clinical and radiological results after arthroscopically assisted stabilization of high-grade AC joint separations using the double TightRope technique [28]. Good-to-excellent early clinical results with a mean CMS were 91.5 points, a mean Taft score of 10.5 points and a mean ACJI of 79.9 points could be achieved despite the presence of partial recurrent vertical and horizontal AC joint instability. Similarly, Salzmann et al. found comparable clinical results after a midterm-term follow-up [27]. However, this technique, in contrast to the MINAR, should only be performed by an experienced arthroscopist [27]. Clinical results of the MINAR technique are encouraging and comparable to those published for the TightRope technique [23, 25, 38]. Twenty-three patients with an acute dislocation of the AC joint were operated with the MINAR. The mean Constant Score was 94.1 points after a mean follow-up of 23.3 months. In two cases, a slight loss of reduction of less than half of the clavicle width in comparison with the contralateral side was observed. But this residual vertical instability did not affect the clinical results. In another study, similar results were reported for the MINAR in 63 patients with a mean follow-up of 39 months [31, 36, 37].

6 For the first generation of the TightRope device, partial loss of reduction due to distal migration of the flip button within the upper third of the clavicle was described in onefourth of the cases [20, 35]. After these reports, the design of the clavicular flip button was changed. In the present study, no distal migration of the larger flip tack was detected. This is the first comparative study on a CC flip button repair versus HP fixation for an acute AC joint dislocation, demonstrating that equal results can be achieved. Higher incidence of ossifications along the CC ligament in the MINAR group was the only difference. However, these ossifications did not have a significant influence on the functional outcome and can therefore be neglected. Some limitations apply to the present study. The study was not randomised, and the number of patients was small. One must consider the rarity of high-grade injuries and the small number of high-demand patients who need surgical intervention in a type III injury. Nonetheless, the number of patients is comparable to most other previous studies. The mean follow-up period was short, but as the clavicle remained reduced for a minimum of 24 months after surgery, a deterioration of clavicular reduction in the long term need not to be expected. However, a longer follow-up will be necessary to determine the incidence of posttraumatic arthritis due to persistent instability, particularly in the horizontal plane. Conclusion The MINAR represents a safe technique for AC joint reconstruction in acute AC joint instability and yields good early clinical results comparable to HP fixation despite the incidence of partial recurrent vertical and horizontal instability. In contrast to HP fixation, a second operation for implant removal is not required after MINAR. References 1. Baker JE, Nicandri GT, Young DC, Owen JR, Wayne JS (2003) A cadaveric study examining acromioclavicular joint congruity after different methods of coracoclavicular loop repair. J Shoulder Elbow Surg 12: Bannister GC, Wallace WA, Stableforth PG, Hutson MA (1989) The management of acute acromioclavicular dislocation: a randomised prospective controlled trial. J Bone Joint Surg Br 71: Blatter G, Meier G (1990) Augmentation of the coraco-clavicular ligament suture. Comparison between wire cerclage, vicryl tape and PDS cord. Unfallchirurg 93: Coale RM, Hollister SJ, Dines JS, Allen AA, Bedi A (2012) Anatomic considerations of transclavicular-transcoracoid drilling for coracoclavicular ligament reconstruction. J Shoulder Elbow Surg 22(1): Constant CR, Murley AH (1987) A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 214: Di Francesco A, Zoccali C, Colafarina O, Pizzoferrato R, Flamini S (2012) The use of hook plate in type III and V acromio-clavicular Rockwood dislocations: clinical and radiological midterm results and MRI evaluation in 42 patients. Injury 43(2): Dimakopoulos P, Panagopoulos A, Syggelos SA, Panagiotopoulos E, Lambiris E (2006) Double-loop suture repair for acute acromioclavicular joint disruption. Am J Sports Med 34(7): Eschler A, Gradl G, Gierer P, Mittlmeier T, Beck M (2012) Results after AC joint repair with the hook plate. Arch Orthop Trauma Surg 132(1): El Sallakh SA et al (2012) Evaluation of arthroscopic stabilization of acute acromioclavicular joint dislocation using the Tight- Rope system. Orthopedics 35(1): Ferreira JV et al (2012) Biomechanical evaluation of effect of coracoid tunnel placement on load to failure of fixation during repair of acromioclavicular joint dislocations. Arthroscopy 28(9): Guttmann D, Paksima NE, Zuckerman JD (2000) Complications of treatment of complete acromioclavicular joint dislocations. Instr Course Lect 49: Greiner S, Braunsdorf J, Perka C, Herrmann S, Scheffler S (2009) Mid to long-term results of open acromioclavicular-joint reconstruction using polydioxanone sulfate cerclage augmentation. Arch Orthop Trauma Surg 129(6): Von Heideken J, Boston Windhamre H et al (2013) Acute surgical treatment of acromioclavicular dislocation type V with a hook plate: superiority to late reconstruction. J Shoulder Elbow Surg 22(1): Jerosch J, Filler T, Peuker E, Greig M, Siewering U (1999) Which stabilization technique corrects anatomy best in patients with ACseparation? An experimental study. Knee Surg Sports Traumatol Arthrosc 7: Jensen G, Katthagen JC et al (2014) Has the arthroscopically assisted reduction of acute AC joint separations with the double tight-rope technique advantages over the clavicular hook plate fixation? Knee Surg Sports Traumatol Arthrosc 22(2): Jobe FW, Bradley JP (1989) The diagnosis and nonoperative treatment of shoulder injuries in athletes. Clin Sports Med 8: Kienast B, Thietje R, Queitsch C, Gille J, Schulz AP, Meiners J (2011) Mid-term results after operative treatment of rockwood grade III-V acromioclavicular joint dislocations with an AChook-plate. Eur J Med Res 24;16(2): Lemos MJ et al (1998) The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med 26: Lindsey RW, Gutowski WT et al (1986) The migration of a broken pin following fixation of the acromioclavicular joint: a case report and review of the literature. Orthopedics 9: Liu X, Huangfu X, Zhao J (2013) Arthroscopic treatment of acute acromioclavicular joint dislocation by coracoclavicular ligament augmentation. Knee Surg Sports Traumatol Arthosc. doi: / s Morrison DS, Lemos MJ et al (1995) Acromioclavicular separation: reconstruction using synthetic loop augmentation. Am J Sports Med 23: Motamedi AR, Blevins FT, Willis MC, McNally TP, Shahinpoor M (2000) Biomechanics of the coracoclavicular ligament complex and augmentations used in its repair and reconstruction. Am J Sports Med 28: Murena L, Vulcano E, Ratti C, Cecconello L, Rolla PR, Surace MF (2009) Arthroscopic treatment of acute acromioclavicular joint dislocation with double flip button. Knee Surg Sports Traumatol Arthrosc 17(12): Norrell H Jr, Llewellyn RC et al (1965) Migration of a threaded Steinmann pin from an acromioclavicular joint into the spinal canal: a case report. J Bone Joint Surg Am 47:

7 25. Patzer T, Clauss C et al (2012) Arthroscopically assisted reduction of acute acromioclavicular joint separations: comparison of clinical and radiological results of single versus double Tight- Rope tech-nique. Unfallchirurg 116(5): Pauly S, Gerhardt C, Haas NP, Scheibel M (2009) Prevalence of concomitant intraarticular lesions in patients treated operatively for high-grade acromioclavicular joint separations. Knee Surg Sports Traumatol Arthrosc 17(5): Petersen W, Wellmann M, Rosslenbroich S, Zantop T (2010) Minimally invasive acromioclavicular joint reconstruction (MINAR)]. Oper Orthop Traumatol 22(1): Rockwood CA Jr, Williams GR Jr, Young DC (1998) Disorders of the acromioclavicular joint. In: Rockwood CA Jr, Matsen FA III (eds) The shoulder, 2nd edn. WB Saunders, Philadelphia, pp Salem KH, Schmelz A (2009) Treatment of Tossy III acromioclavicular joint injuries using hook plates and ligament suture. J Orthop Trauma 23(8): Salzmann GM, Walz L, Buchmann S, Glabgly P, Venjakob A, Imhoff AB (2010) Arthroscopically assisted 2-bundle anatomical reduction of acute acromioclavicular joint separations. Am J Sports Med 38(6): Scheibel M, Dröschel S, Gerhardt C, Kraus N (2011) Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations. Am J Sports Med 39(7): Schliemann B, Roßlenbroich SB et al (2013) Why does minimally invasive coracoclavicular ligament reconstruction using a flip button repair technique fail? Knee Surg Sports Traumatol Arthrosc, A analysis of risk factors and complications. doi: /s z 33. Sim E, Schwarz N, Hocker K, Berzlanovich A (1995) Repair of complete acromioclavicular separations using the acromioclavicular-hook plate. Clin Orthop Relat Res 314: Taft TN, Wilson FC, Oglesby JW (1987) Dislocation of the acromioclavicular joint: an end-result study. J Bone Joint Surg Am 69: Thiel E, Mutnal A, Gilot GJ (2011) Surgical outcome following arthroscopic fixation of acromioclavicular joint disruption with the tightrope device. Orthopedics 34(7):e267 e Tischer T, Salzmann GM, El-Azab H, Vogt S, Imhoff AB (2009) Incidence of associated injuries with acute acromioclavicular joint dislocations types III through V. Am J Sports Med 37(1): Wellmann M, Zantop T, Petersen W (2007) Minimally invasive coracoclavicular ligament augmentation with a flip button/polydioxanone repair for treatment of total acromioclavicular joint dislocation. Arthroscopy 23(10):1132.e e5 38. Wellmann M, Zantop T, Weimann A, Raschke MJ, Petersen W (2007) Biomechanical evaluation of minimally invasive repairs for complete acromioclavicular joint dislocation. Am J Sports Med 35(6):