Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Case Report
Clinical research study
Current Issue
Editorial Board
Literature Review
Narrative review
Original Article
Research Article
Review Article
Short Report
Surgical techniques
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Case Report
Clinical research study
Current Issue
Editorial Board
Literature Review
Narrative review
Original Article
Research Article
Review Article
Short Report
Surgical techniques
View/Download PDF

Translate this page into:

59 (); 13-21
doi:
10.1016/j.jor.2024.07.015

Outcomes of arthroscopic coracoclavicular management for acromioclavicular joint injuries: A systematic review

, , , , ,
a Northwestern University Feinberg School of Medicine, Chicago, IL, USA
b Rothman Orthopaedic Institute, New York, NY, USA
c Department of Orthopaedic Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
d Department of Orthopaedic Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada

⁎Corresponding author: Moin Khan. khanmm2@mcmaster.ca

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Various surgical procedures for coracoclavicular (CC) ligament repair have been described for symptomatic acromioclavicular joint dislocations, with none emerging as a clear gold standard. There has been increased interest in arthroscopic approaches. This systematic review evaluates clinical outcomes after arthroscopic surgeries used to treat chronic and acute AC joint dislocations.

We searched three databases (PubMed, EMBASE, and OVID [MEDLINE]) from database inception to December 20, 2022. Studies were included if they met the following criteria: studies evaluating humans, English language studies, level of evidence I to IV, and studies investigating clinical outcomes in patients following arthroscopic surgery for coracoclavicular ligament reconstruction. Studies on open reconstruction techniques only were excluded. Primary outcomes included function/pain scores, coracoclavicular distances, complications, and revision rates.

Fifty-two studies were included. In 33 studies, postoperative Constant-Murley scores ranged from 82.8 to 99 points. Postoperative VAS scores ranged from 0.3 to 4.1 in 16 studies. In 46 studies, revision rates ranged from 0 % to 44.4 %. We did not observe a difference in revision rates between chronic and acute cases (P = 0.268). Complications were more common in chronic than acute cases (25.5 % vs. 16.4 %; P < 0.001).

Arthroscopic surgery for chronic and acute CC ligament injuries exceeds the MCID and PASS for several outcomes, with low failure rates. Arthroscopic CC reconstruction is a safe and effective alternative for chronic AC joint dislocations.

IV (Systematic Review of Level I-IV Studies)

Keywords

Arthroscopy
Coracoclavicular
Reconstruction
Outcomes
Systematic review
1

1 Introduction

Acromioclavicular (AC) joint dislocations can result in disruption of the AC ligament, coracoclavicular (CC) ligament, and deltopectoral fascia, depending on severity of injury.3 The Rockwood classification system identifies six grades of injury, considering the integrity of the AC and CC ligaments, direction of clavicular dislocation, and clavicular attachment with the deltoid and trapezius muscles.22 The current consensus for managing AC joint dislocations recommends non-operative management of Rockwood I and II injuries, while types IV, V, and VI are generally treated surgically.4 Type III injuries are typically managed nonoperatively; however, conservative treatments do not achieve active reduction of the dislocation, and studies have found that patients may experience long-term chronic pain and degeneration of the AC joint without surgery, particularly in horizontally unstable injury patterns.31 Therefore, some have advocated surgical treatment for type III injuries in young, active patients.

Surgical management of AC joint dislocations is dependent on chronicity of injury; while there are various techniques to maintain reduction of acute AC joint injuries (ORIF with hook plate, ORIF with tight rope, Bosworth screw, etc), chronic dislocations generally require reconstruction of the CC ligaments with allograft augmentation.19 Several studies have demonstrated the important role of the CC ligaments in stabilizing the AC joint, and as a result, procedures for CC ligament reconstruction have been developed.39

Traditionally, open surgical procedures were most common; however, arthroscopic techniques for the management of CC ligament injuries have been developed with the advancement of arthroscopy in recent years.50 Advantages of arthroscopic techniques including improved visualization, decreased soft tissue stripping and invasiveness, and the access to find and manage concomitant glenohumeral injuries that are often found in more severe dislocations.38

Transitioning from open to arthroscopic techniques for surgical procedures often can entail a learning curve and it is important to ensure that techniques remain safe and effective without compromising patient outcomes.75,76 Data studying the learning curve for surgeons when transitioning from open to arthroscopic Latarjet technique for recurrent shoulder dislocations is instructive. In a systematic review, Ekhtiari et al. observed that the most commonly reported difference was that surgeons earlier in the learning curve needed longer operative times.18 However, other factors like complication rates, patient-reported outcomes, and technical characteristics such as screw angle and graft position did not differ based on experience. The same thorough analysis of the literature on arthroscopic CC ligament reconstruction is lacking.

This systematic review evaluates clinical outcomes following arthroscopic management of acute and chronic CC ligament injuries to determine its effectiveness and safety in treating symptomatic AC joint dislocations.

2

2 Methods

2.1

2.1 Search strategy

We searched three databases (PubMed, Ovid Medline, and EMBASE) for articles discussing arthroscopic coracoclavicular ligament reconstruction published from database inception to December 20, 2022. The search was performed using the terms: “acromioclavicular joint injury,” “acromioclavicular joint separation,” “shoulder separation,” “arthroscopic coracoclavicular ligament reconstruction,” “arthroscopic coracoclavicular reconstruction,” “arthroscopic coracoclavicular,” and “coracoclavicular ligament reconstruction.”

2.2

2.2 Study screening

Two reviewers performed study screening for the titles, abstracts, and full-text articles independently and in duplicate. Study screening was performed per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. In the instance of disagreement during the title and abstract screenings, articles were moved onto the next stage for further review. In the full-text screening, any disagreements were resolved by a senior author.

2.3

2.3 Assessment of study eligibility

Both our research question and study eligibility criteria were determined a priori. The following inclusion criteria was used: English language studies, studies evaluating humans, level of evidence I to IV, and studies investigating clinical outcomes in patients following arthroscopic surgery for coracoclavicular ligament reconstruction. Studies on open reconstruction techniques only were excluded. Review articles, book chapters, commentaries, technique papers, animal studies, and case series with <5 patients were also excluded.

2.4

2.4 Data abstraction and statistical analysis

Two reviewers collected the data, which was stored using Microsoft Excel (Version 2019, Microsoft, Redmond, WA, USA). Basic data regarding the article included author information, year published, study design, and study sample sizes. Sex ratios, mean age, mean follow-up in months, and details of surgical management were collected. A variety of shoulder-specific outcome measures were included, such as the American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CMS), Subjective Shoulder Value (SSV), and University of California at Los Angeles (UCLA) Shoulder scores. Visual Analog Scale (VAS) and 36-Item Short Form Survey scores were also utilized. Scores specific to the acromioclavicular joint were also evaluated, including Acromioclavicular Joint Instability (ACJI) and Taft Scores (TS). The ACJI score was described by Scheibal et al. as an acromioclavicular joint specific outcome measure.59 The ACJI is graded out of 100 total points encompassing five categories: radiological evaluation (35 points), function (25 points), pain (20 points), cosmesis (10 points), and activities of daily living (10 points). The Taft Score was developed to score results following both conservative and surgical management of AC joint dislocations and has a maximum score of 12 points that includes subjective, objective, and radiologic criteria.68

Additionally, post-operative revision rates, complications data, and coracoclavicular distances (CCD) measured at rest and using stress views were reported. Data was collected for various time points in patient care and grouped accordingly when relevant.

Descriptive statistics were collected, including means, standard deviations, proportions, ranges, and 95 % confidence intervals (CI). Additionally, when preoperative and postoperative data was available for patient-reported scores, mean percent (%) differences were calculated. For complications and revision rates, a subgroup analysis was performed between chronic and acute AC joint injuries (CC ligament reconstruction versus arthroscopic reduction internal fixation). Pooling of final follow-up scores was planned in acute and chronic cohorts. Outcomes will be reported as means, with standard deviation/standard error measurements, in >1 studies. Unpaired t-tests will be used to identify differences between chronic and acute cohorts, with an a priori level of significance at P < 0.05. We attempted a similar analysis for graft vs. no graft procedures; however, the data did not allow for this since almost all chronic cases were reconstructed with graft, while acute cases had variable constructs used. As a result, the chronic vs. acute analysis is comparable to graft vs. no graft.

2.5

2.5 Study quality assessment

Studies included in our review were assessed using the MINORS instrument, which was designed to evaluate the quality of non-randomized, comparative and non-comparative studies.66 The highest score on the MINORS checklist is 16 for non-comparative studies and 24 for comparative studies. For randomized controlled trials, the Cochrane risk of bias tool was utilized to determine study quality.25 There are 8 types of bias evaluated by the Cochrane tool; namely: allocation concealment, blinding of personnel/participants, blinding of the data analyst, blinding of the outcome evaluation, selective reporting, incomplete outcome data, random sequence generation, and “other” biases.

2.6

2.6 Assessment of agreement

A kappa (κ) statistic was calculated to evaluate inter-reviewer agreement for the title, abstract, and full-text screening stages. The level of agreement was established a priori with the following guidelines: κ of 0.61 or greater was viewed to be “substantial” agreement; κ of 0.41–0.6 was determined to be “moderate” agreement; and κ/ICC of 0.20–0.40 was categorized as “slight” agreement.

3

3 Results

3.1

3.1 Study characteristics and demographics

A total of 52 studies were included in the final quantitative analysis, of which 2 were randomized controlled trials, 15 were cohort studies, 34 were case series studies, and 1 was a case control study (Fig. 1).1–45,46–77 In noncomparative studies, the average MINORS score was 12.0 (ranging from 10 to 14). In comparative studies, the average MINORS score was 17.2 (ranging from 15 to 20). All studies were clear in their aims, appropriately included of patients, had an a priori established plan for data collection, and created adequate endpoints. Only one study (2 %) had blinding of endpoints, while 94 % of studies had appropriate follow-up periods, and 56 % of studies had a loss to follow-up of less than 5 %. No studies prospectively calculated the study size needed to detect a difference in outcomes. The evaluations of study bias performed for RCTs included in this review are outlined in Table 2 and they were of overall moderate quality. In the evaluation of agreement between reviewers, κ was 0.41 for the title screening, 0.61 for the abstract screening, and 0.87 for the full-text screening.

Flow diagram demonstrating the systematic screening of the literature.
Fig. 1 Flow diagram demonstrating the systematic screening of the literature.
Table 1 Summary of studies.
Authors (Year) Study Design MINORS Score Number of Patients % Male Age (Years) Follow-Up (Months) Rockwood InjuryClassification
Chernchujit et al. (2006) Case Series 12 13 84.6 % 40.2 18 6 IV, 7 V
Murena et al. (2009) Case Series 12 16 93.8 % 33.3 31 10 III, 4 IV, 2 V
Boileau et al. (2010) Case Series 12 10 80.0 % 41.0 12.8 3 III, 5 IV, 2 V
Salzmann et al. (2010) Case Series 11 23 91.3 % 37.5 58 3 III, 3 IV, 17 V
Defoort et al. (2010) Cohort Study 18 Group 1: 9Group 2: 7a 87.5 % (Overall Cohort) 39.6 (Overall Cohort) 17 (Overall Cohort) Group 1: 2 III, 7 IVGroup 2: 4 III, 3 IV
Scheibel et al. (2011) Case Series 11 28 92.9 % 38.8 26.5 28 V
Yoo et al. (2011) Case Series 12 13 76.9 % 28.4 17 3 III, 10 V
El Sallakh (2012) Case Series 11 11 90.9 % 26.0 N/A 3 IV, 8 V
Cook et al. (2012) Case Series 12 9 100.0 % 25.9 9.7 2 III, 7 IV
Milewski et al. (2012) Case Series 11 10 80.0 % 31.4 5.3 2 III, 8 V
Jensen et al. (2013) Case Series 10 16 87.5 % 40 13 11 III, 5 V
Kraus et al. (2013) Cohort Study 18 Group 1: 15Group 2: 13a Group 1: 93.3 %Group 2: 92.3 % Group 1: 37.7Group 2: 40.9 24 (Overall Cohort) Group 1: 15 V
Jensen et al. (2014) Cohort Study 18 Group 1: 26Group 2: 30a Group 1: 88.5 %Group 2: 93.3 % Group 1: 39Group 2: 39 Group 1: 17Group 2: 48 Group 1: 10 III, 16 VGroup 2: 12 III, 18 V
Liu et al. (2015) Case Series 12 12 66.67 48.0 24 7 III, 5 V
Shin et al. (2015) Case Series 12 18 94.44 45.4 25.6 3 III, 1 IV, 14 V
Parnes et al. (2015) Case Series 12 12 100.00 25.0 30.4 12 V
Loriaut et al. (2015) Case Series 11 39 66.67 35.7 42.3 28 III, 11 IV
Clavert et al. (2015) Case Series 12 116 82.76 37 N/A 56 III, 35 IV, 25 V
Chaudhary et al. (2015) Case Series 12 17 88.2 % 35.0 22.1 6 III, 1 IV, 10 V
Singh et al. (2016) Case Series 12 9 88.9 % 38.4 22.8 4 III, 2 IV, 2 V, 1Fracture
Faggiani et al. (2016) Cohort Study 17 Group 1: 8Group 2: 8a 93.8 % (Overall Cohort) 36.9 (Overall Cohort) 13.0 (Overall Cohort) Group 1: 4 III, 4 IVGroup 2: 4 III, 4 IV
Takase et al. (2016) Case Series 12 22 86.4 % 38.1 38 22 V
Tauber et al. (2016) Cohort Study 18 Group 1: 12Group 2: 14 92.3 % (Overall Cohort) Group 1: 41.3Group 2: 51.3 Group 1: 27.1Group 2: 31.2 Group 1: 3 III, 4 IV, 5 VGroup 2: 3 III, 1 IV, 10 V
Cisneros et al. (2017) Cohort Study 17 Group 1: 20Group 2: 12Group 3: 10Group 4: 11a Group 1: 85.0 %Group 2: 100.0 %Group 3: 100.0 %Group 4: 100.0 % Group 1: 36Group 2: 31Group 3: 41Group 4: 41 N/A Group 1: 3 III, 3 IV, 14 VGroup 2: 3 III, 2 IV, 7 VGroup 3: 1 III, 1 IV, 8 VGroup 4: 5 III, 6 V
Shin et al. (2017) Case Series 11 21 95.2 % 41.1 27.2 7 III, 14 V
Zhang et al. (2017) Case Series 11 24 87.5 % 28.7 39.5 8 III, 16 V
Lee et al. (2017) Case Series 12 47 74.5 % 37 N/A 15 III, 2 IV, 30 V
Hann et al. (2018) Case Series 11 34 85.3 % 43.3 26.4 34 V
Bin Abd Razak et al. (2018) Case Control 20 16 93.8 % 41.4 23 N/A
Issa et al. (2018) Case Series 11 19 84.2 % 34.4 76.9 15 III, 4 IV
Athar et al. (2018) RCT N/A 24 4.2 % 42.6 N/A 16 III/IV, 8 V
Xu et al. (2018) Cohort Study 18 Group 1: 39Group 2: 39 Group 1: 76.9 %Group 2: 71.8 % Group 1: 29.4Group 2: 31.2 >2 years Group 1: 39 IVGroup 2: 39 IV
Stein et al. (2018) Cohort Study 19 Group 1: 29Group 2: 27a Group 1: 96.6 %Group 2: 96.3 % Group 1: 34.2Group 2: 37.7 N/A Group 1: 8 III, 1 IV, 20 VGroup 2: 3 III, 4 IV, 20 V
Hashiguchi et al. (2018) Case Series 12 12 100.0 % 40.8 106.3 8 III, 4 V
Jobmann et al. (2019) Case Series 12 55 N/A 35.2 >6.5 months, >16.0 months N/A
Lee et al. (2019) Case Series 12 27 74.1 % 35.2 27.2 12 III, 15 V
Kraus et al. (2019) Cohort Study 15 Group 1: 14Group 2: 13a Group 1: 21.4 %Group 2: 46.2 % Group 1: 47.2Group 2: 44.9 Group 1: 24.3Group 2: 28.8 2 II, 19 III, 17 V (Overall Cohort)
Lim et al. (2019) Case Series 12 18 66.7 % 47 17 10 V, 3 III, 5 Neer IIb
Boileau et al. (2019) Case Series 12 57 86.0 % 42 36 11 III, 19 IV, 27 V
Thangaraju et al. (2019) Case Series 12 20 100.0 % 40 4.5 20 IV/V
Abdelrahman et al. (2019) RCT N/A 22 68.2 % 31 24 16 III, 6 IV
Seo et al. (2019) Cohort Study 18 Group 1: 11Group 2: 21 Group 1: 100.0 %Group 2: 79.2 % Group 1: 47.2Group 2: 51.6 Group 1: 13.6Group 2: 13.7 N/A
Çarkçı et al. (2020) Cohort Study 17 Group 1: 27Group 2: 9 Group 1: 88.9 %Group 2: 88.9 % Group 1: 29.9Group 2: 32.6 Group 1: 32.1Group 2: 29.3 14 III, 22 V
Lamplot et al. (2020) Case Series 11 88 89.8 % 39.6 73.2 32 III, 56 V
Campagna et al. (2021) Case Series 14 41 85.4 % 31.3 35 33 III, 8 V
Yoo et al. (2021) Cohort Study 19 Group 1: 12Group 2: 10a Group 1: 66.7 %Group 2: 70.0 % Group 1: 42.8Group 2: 44.4 Group 1: 30.1Group 2: 33.8 Group 1: 5 III, 7 VGroup 2: 5 III, 5 V
Voss A et al. (2021) Cohort Study 17 Group 1: 15Group 2: 15a Group 1: 100.0 %Group 2: 100.0 % Group 1: 31.9Group 2: 33.5 24.7 (Overall Cohort) Group 1: 6 IV, 9 VGroup 2: 10 IV, 5 V
Murphy et al. (2021) Case Series 11 23 87.0 % 41 26 3 III, 2 IV, 18 V
Li et al. (2021) Case Series 11 48 81.3 % 43.8 39.3 5 IV, 43 V
Nie et al. (2021) Cohort Study 20 Group 1: 28Group 2: 84a Group 1: 78.6 %Group 2: 78.6 % Group 1: 35.9Group 2: 36.0 Group 1: 33.1Group 2: 32.9 Group 1: 2 III, 16 V, 10 VGroup 2: 4 III, 46 IV, 34 V
Nolte et al. (2021) Case Series 12 102 90.2 % 45.0 56.4 49 III, 8 IV, 45 V
Marsalli et al. (2021) Cohort Study 14 102 95.0 % 37.3 20.8 weeks 102 V
a Not included in our analyses.
Table 2 Evaluation of bias for randomized controlled trials.
Authors (Year) Random Sequence Generation Allocation Concealment Blinding of Participants and Personnel Blinding of Outcome Assessment Blinding of Data Analyst Incomplete Outcome Data Selective Reporting Other Bias
Athar et al. (2018) High Unclear High Unclear Unclear Low Low Low
Abdelrahman et al. (2019) Low Low High High Unclear Low Low Low

Sample sizes in included studies ranged from 8 to 116 individuals. The age of patients ranged from 18 to 70. The percentage of male patients ranged from 4.2 % to 100 %. The final follow-up of the included studies ranged from 0.5 to 128 months (See Table 1 for details).

3.2

3.2 Surgical techniques

Regarding surgical technique, 40 studies utilized beach chair positioning, 3 studies used lateral decubitus positioning, 4 used other modified positioning, and 5 did not report positioning. Two arthroscopic portals were used in 20 studies, 3 portals in 24 studies, and 4+ portals in 2 studies. Six articles did not report the number of portals used.

Thirty-eight studies reported the surgical management of acute AC joint injuries, while 10 evaluated reconstructions following chronic injuries. Four studies reported data from both acute and chronic injuries.

In 43 cohorts evaluating arthroscopic management of acute injuries, common surgical constructs included TightRope fixation (n = 25 studies), EndoButton constructs (n = 7), DogBone/Fiberwire/Tigerwire cortical buttons (n = 6), and others (n = 5). In 12 chronic injury cohorts, surgical constructs were GraftRope fixation (n = 3), Single EndoButton and Double-Button constructs (n = 2), tenodesis screws (n = 4), ZipTight fixation (n = 1), TightRope fixation (n = 1), and anchors (n = 1). Almost all chronic reconstructions used a graft along with the aforementioned constructs to reproduce the CC ligaments. Out of the 12 chronic injury cohorts, 6 exclusively used autografts for reconstruction of the CC ligaments, 2 used allografts, 3 used either allograft or autograft, and 1 did not use grafting.

The majority of patients underwent surgery for injuries of Rockwood classification III, IV, or V. The breakdown of injury classification varied between studies (See Table 1 for details).

3.3

3.3 Summary of primary outcome variables

Postoperative ACJI scores taken at the final follow-up were reported in 5 studies, ranging from 58.4 to 89.5 points (Table 3). Scores were ≥84.5 points in 4 of 7 total cohorts.

Table 3 Summary of postoperative outcome scores.
Outcome Score # of Studies (# of Cohorts) # of Chronic vs.Acute Cohorts Follow-UpRange (Months) Postoperative Score Range Range in Chronic Cohorts Range in Acute Cohorts
Acromioclavicular Joint Instability 5 (7) 3 Chronic4 Acute 24.0 to 31.2 58.4 to 89.5 58.4 to 89.5 75.9 to 87.0
American Shoulder and Elbow Surgeons 7 (8) 2 Chronic5 Acute1 Chronic + Acute 13.6 to 54.6 86.3 to 96.6 88.0 to 95.3 86.3 to 95.7
Constant-Murley Scores 32 (36) 6 Chronic30 Acute 13.0 to 76.9 82.8 to 99.0 84.0 to 96.0 82.8 to 99
SF-36 Physical Component 3 (5) 1 Chronic3 Acute1 Chronic + Acute 24.0 to 56.4 56.2 to 59.6 59.6 56.2 to 58.3
SF-36 Mental Component 2 (4) 1 Chronic3 Acute >24.0 51.1 to 56.6 56.6 51.1 to 56.2
Subjective Shoulder Value 11 (13) 6 Chronic7 Acute 12.8 to 36.0 78.0 to 95.0 78.0 to 95.0 90.0 to 96.2
Taft Score 10 (12) 4 Chronic8 Acute 13.0 to 31.2 9.0 to 11.1 9.0 to 11.0 10.0 to 11.1
UCLA Shoulder 6 (6) 1 Chronic5 Acute 12.8 to 39.5 16.5 to 31.7 16.5 28.4 to 31.7
Visual Analog Scale 16 (17) 2 Chronic15 Acute 13.0 to 76.9 0.3 to 4.1 0.6 to 4.1 0.3 to 1.8

The ASES score was reported in 7 studies with 8 cohorts, of which 2 included both preoperative and postoperative measurements. Scores at final follow-up ranged from 86.3 to 96.6 points. Mean percentage difference was only evaluated in one study (31.45 %), since the other articles including preoperative scores only provided median values.

Constant-Murley scores were measured in 32 studies with 36 cohorts, of which 15 included preoperative comparison values. CMS values at final follow-up ranged from 82.8 to 99 points, with 22 studies having scores ≥90 points. Ten studies had average postoperative scores ≥95 points. The average difference between pre- and post-operative scores ranged from 11.2 to 69.5 (mean % change from 15.8 % to 408.8 %). Nine studies found mean improvements >100 %. Two studies measured CMS scores across four time points: 1) preoperatively, 2) at 6 months, 3) at 12 months, and 4) at 24 months. Salzmann et al. demonstrated improvement from 27.45 points preoperatively to 85.79 at 6 months, 93.34 at 12 months, and 95.31 at 24 months.58 Stein et al. showed improvement from 34.5 points preoperatively to 89.0 at 6 months, 93.9 at 12 months, and 94.3 at 24 months.67

Postoperative SF-36 Physical Component scores were reported in 3 studies with 5 cohorts. Scores ranged from 56.2 to 59.6. In 2 studies, the mean difference between pre- and final post-operative scores were 14.4 (mean % change: 34.3 %) and 9.5 (mean % change: 20.6 %).

In 2 studies with 4 cohorts, final SF-36 Mental Component scores ranged from 51.1 to 56.6. The mean difference between pre-operative and final post-operative scores was only calculated in one study, measuring at 1.8 points (3.7 %).

Final postoperative SSV scores were reported in 11 studies with 13 cohorts. Six cohorts included preoperative values. Preoperative scores ranged from 32.9 to 72.3. Final postoperative scores ranged from 78.0 to 95.0, and 9 studies had postoperative values ≥ 90 points. Mean differences between pre-operative and final postoperative scores ranged from 20.1 to 62.1 points (mean % difference ranged from 27.9 % to 194.1 %). Two studies showed % difference improvements greater than 100 % (129.2 % and 194.1 %).

In 10 studies with 12 cohorts, final Taft scores ranged from 9.0 to 11.1. Preoperative scores were reported in 3 studies and ranged from 3.1 to 9.2. The mean difference between pre-operative and final post-operative scores was reported in these 3 studies and ranged from 1.9 to 7.8 (mean % change ranged from 20.7 % to 251.6 %).

Final follow-up UCLA Shoulder scores were included in 6 studies and ranged from 16.5 to 31.7. Four studies had average scores ≥30 points. In 3 studies, the mean difference between preoperative and final postoperative UCLA Shoulder scores ranged from 12.9 to 22.3, with mean % changes from 75.9 % to 237.2 %.

In 16 studies with 17 cohorts, final postoperative VAS scores ranged from 0.3 to 4.1. Sixteen cohorts (94.1 %) had final VAS scores ≤2, and 7 (41.2 %) had scores ≤0.6. In 10 cohorts, preoperative VAS scores ranged from 4.2 to 8.3. The mean difference between pre-operative and final post-operative VAS scores ranged from −3.2 to −7.5 (mean % change ranged from −70.5 % to −94.1 %).

In 51 studies with 56 cohorts and 1550 patients, a total of 277 complications (17.8 %) were reported. Of the 277 complications, the most reported were coracoid/clavicle tunnel widening (N = 68, 24.5 %), recurrent vertical/horizontal instability (N = 57, 20.6 %), hardware failures (N = 48, 17.3 %), infections (N = 23, 8.3 %), coracoid/clavicular fractures (N = 14, 5.1 %), and intraoperative complications (N = 14, 5.1 %). In 43 total cohorts with 1173 patients who experienced acute injuries, a total of 192 complications (16.4 %) were recorded. In 12 chronic injury cohorts with 306 patients, 78 complications (25.5 %) were observed. A chi-squared test of independence showed that patients undergoing arthroscopic surgery for chronic injuries were more likely to experience complications than counterparts with acute injuries, χ2 (1, N = 1448) = 13.5, p < 0.001. The most common complication in acute cases was coracoid/clavicle tunnel widening (N = 48, 27.1 %), followed by hardware failure (N = 35, 19.8 %), recurrent vertical/horizontal instability (N = 29, 16.4 %), infections (N = 15, 8.5 %), coracoid/clavicle fractures (N = 7, 4.0 %), and intraoperative complications (N = 4, 2.3 %). The remaining 54 complications (28.1 %) were not identified in these categories. In chronic cases, horizontal/vertical instability was the most common complication (N = 26, 33.3 %), followed by coracoid/clavicle tunnel widening (N = 16, 20.5 %), hardware failure (N = 8, 10.3 %), infections (N = 7, 9.0 %), coracoid/clavicle fractures (N = 5, 6.4 %), and intraoperative complications (N = 3, 3.9 %). The remaining 13 complications did not fall in these categories (16.7 %). On chi-square analysis, there was a significant difference in the types of complications experienced by acute vs. chronic cases, χ2 (6, N = 270) = 13.5, p = 0.01.

In 44 studies with 48 cohorts and 1357 patients, revision rates ranged from 0 % to 44.4 %. Twenty-six cohorts (54.2 %) did not report any patients needing revision surgery. A further 6 cohorts (12.5 %) had revision rates ≤5 %, and 9 (18.4 %) had rates <8 %. Across all studies, 76 patients (5.6 %) required revision surgery. In 34 acute injury cohorts with 969 patients, there were 43 total revisions (4.4 %). In 11 chronic injury cohorts with 263 patients, 16 revisions were reported (6.1 %). There was no difference between groups, χ2 (1, N = 1232) = 1.2, p = 0.268.

Coracoclavicular distances were measured using rest views in 7 studies and stress views in 5 studies. At rest, mean preoperative CCD ranged from 13.5 to 29.1 mm (mm). Distances measured immediately after the operation was performed ranged from 5.7 to 11.4 mm, and final follow-up values ranged between 7.3 and 11.8 mm. In five studies reporting both pre- and final post-operative CCD, the mean difference ranged from −4.6 to −17.3 mm, with % differences from −28.8 % to −59.7 %. In studies using stress views, CCD values ranged between 16.1 and 31.9 mm. Final measurements ranged from 10.5 to 16.9 mm, with mean differences from −5.6 to −15.0 mm (% differences from −33.0 % to −50.0 %).

Loss of reduction (LOR) information was provided in 46 studies with 49 cohorts and 1326 patients. Rates of LOR ranged from 0.0 % to 88.9 %. Across all studies, a total of 216 patients (16.3 %) experienced postoperative loss of reduction. There was substantial variation in the definitions and severity of LOR (see Table 4 for a detailed breakdown).

Table 4 Loss of reduction data.
Loss of Reduction Definition # of Cases (% of All LOR Cases)
Loss of reduction >2 mm 19 (9.9 %)
Loss of reduction >3 mm 10 (4.6 %)
Loss of reduction >5 mm 17 (7.9 %)
Loss of reduction >8 mm 8 (3.7 %)
Loss of reduction between 2 and 4 mm 10 (4.6 %)
Loss of reduction between 4 and 8 mm 12 (5.6 %)
25 % increase in CCD 23 (10.6 %)
50–100 % increase in CCD 4 (1.9 %)
>100 % increase in CCD 2 (0.9 %)
Defined as “slight” loss of reduction 3 (1.4 %)
Defined as “partial” loss of reduction 14 (6.5 %)
Subluxation 19 (8.8 %)
Complete redislocation 25 (11.6 %)
Unclear 50 (23.1 %)

Comparison of Acute vs. Chronic Cohorts Final Follow-Up Scores:

The Acromioclavicular Joint Instability score was only pooled from 2 chronic cohorts, with a combined value of 71.6±14.3. There was insufficient data to pool from studies reporting on acute injuries.

A total of 4 acute cohorts reported average postoperative ASES scores with measures for error, with a final pooled score of 92.4±7.5. In 2 chronic cohorts, the final pooled score was 91.7±9.0.

Postoperative Constant-Murley scores were pooled from 17 acute cohorts, with a final value of 92.3±3.8. In comparison, the pooled final Constant-Murley scores in 3 chronic cohorts was 92.4±5.6.

The SF-36 physical component score was reported in 3 acute cohorts, with a pooled value of 57.6±2.2. In 1 chronic cohort, the final SF-36 physical score was 59.6±2.0 (P = 0.309). In 3 acute cohorts, the pooled SF-36 mental component score was 54.2±4.6. In 1 chronic cohort, the SF-36 mental score was 56.6±1.9.

In 2 acute cohorts, the pooled postoperative SSV score was 93.9±6.5. Comparatively, the final SSV score was a bit lower at 84.9±10.9 in 4 total chronic cohorts.

The UCLA Shoulder score was pooled from 3 acute cohorts, with a final value of 31.1±3.2. This was higher than the one study reporting a chronic group, which had an average postoperative score of 16.5±1.8.

Postoperative Taft Scores were pooled from 3 studies reporting acute injuries, with a combined value of 10.9±1.2. In comparison, 2 studies reporting chronic injury data had a pooled score of 10.0±1.8.

Postoperative Visual Analog Scale scores were pooled from 12 total acute cohorts, with a final combined value of 1.0±1.1. The pooled VAS score was 2.4±1.4 in 2 chronic cohorts.

4

4 Discussion

This systematic review presents a comprehensive overview of the literature evaluating clinical and patient-reported outcomes following arthroscopic management of symptomatic CC ligament injuries after AC joint dislocations. The most important finding in this review is that arthroscopic procedures for CC injuries result in substantial improvements in both clinical and patient-reported outcome measures and overall low revision rates.

The Constant-Murley Score (CMS) was the most frequently measured in studies evaluating surgical outcomes after arthroscopic CC reconstruction. Postoperative CMS scores in our study ranged from 82.8 to 99 and can be compared with published data for various open techniques. A systematic review by Moatshe et al. evaluating different techniques for open AC and CC ligament reconstruction found that postoperative CMS scores ranged from 76.4 to 96.0 for free tendon graft, 82.6 to 97.8 for suspensory devices, 85.9 to 97.0 for synthetic ligament devices, 81 to 96 in modified Weaver-Dunn, and 83.0 to 94.6 for hook plate/K-wires techniques.51 Though our analysis does not directly compare CMS scores after arthroscopic and open reconstruction, our findings were similar to the existing literature studying different open techniques for CC reconstruction.

All studies in this review evaluating CMS scores both preoperatively and postoperatively showed substantial improvements, according to quantified estimates for both minimal and substantial clinical benefits (SCB). Studies have estimated the MCID for the CMS score following rotator cuff injuries, with Louwerens et al. identifying values of 9.8 (with a mean change method) and 5.5 (using receiver operating characteristic analysis).44 The same study found a SCB of 19.9, using the mean change method, and 10.5, based on receiver operating characteristic analysis. Similarly, Kukkonen et al. identified an MCID threshold of 10.4 in patients with rotator cuff injuries.34 Included studies in this review showed improvements greater than all previous estimates of MCID in CMS scores. However, it is important to note that no work has previously identified MCID cutoffs for CMS scores after AC joint injuries specifically.

The Visual Analog Scale was used to measure preoperative and postoperative pain in 15 studies.17 Estimates for interpreting VAS scores have suggested that ratings between 0 and 0.4 cm reflect no pain, 0.5–4.4 cm indicate mild pain, 4.5–7.4 cm are moderate pain, and 7.5–10 cm mean severe pain 28. In our study, all postoperative VAS scores indicated that patients had either no pain or mild pain. Previous studies have estimated MCID between preoperative and postoperative VAS scores, however, none have found values specific to AC joint injuries. A recent study by Tashjian et al. estimated the MCID in VAS scores after arthroscopic rotator cuff repair to be 2.4 cm, while previous work by the same authors showed a MCID of 1.4 cm.70,71 In their first study, the authors also identified a Patient Acceptable Symptomatic State (PASS) score at 3 cm. A study performed by Menendez et al. recently determined a MCID value of 1.7 cm and PASS of 2.5 cm in patients undergoing the Latarjet procedure.47 This review found across all studies that arthroscopic CC reconstruction results in improvements in VAS scores that surpassed both MCID and PASS values described in the literature for shoulder pathologies.

The Subjective Shoulder Value, which is expressed as a percentage of function compared with a healthy shoulder (which would score 100 %), was another commonly reported score. Nine out of 11 studies had final postoperative SSV scores ≥90 points, reflecting almost entirely healthy function compared with uninjured shoulders. A previous study by Van de Water et al. used two different methods to estimate a MCID for SSV scores in a cohort of patients with proximal humeral fractures, finding values of 12.1 and 26.6.74 All 6 cohorts saw improvements in SSV scores greater than 12.1, while 4 cohorts had changes in SSV larger than 26.6.

In the included studies, a wide range of complication rates were noted, likely reflecting variation in the arthroscopic techniques being performed as well as heterogeneous criteria for complications between studies. The complication rates can be compared with the open-CC reconstruction data provided in the systematic review by Moatshe et al. which found rates of 10.3 %, 6.2 %, 4.4 %, 12.8 %, and 26.3 % for free graft reconstruction, suspensory devices, ligament advanced reinforcement systems, coracoacromial ligament transfers, and hook plate/k-wires, respectively. Most studies in our review showed similarly low complication rates, suggesting a comparable safety profile of arthroscopic CC reconstruction procedures.

Revision rates were low in most included studies, with a majority of cohorts having no reported revisions (56.25 %) or rates ≤5 % (10.4 %). These revision rates can be compared with data in the existing literature, with the work by Moatshe et al. again being instructive.51 In their systematic review on open CC reconstruction, the authors found unplanned reoperation rates of 0.9 %, 1.2 %, 2.8 %, 2.6 %, and 5.4 % in synthetic ligament devices, free tendon graft, suspensory devices, hook plate/K-wires techniques, and modified Weaver-Dunn, respectively. Although a few studies on arthroscopic CC reconstruction did show higher revision rates than currently described, the majority were comparable to the existing literature on open techniques.

When comparing adverse events between acute and chronic injuries, we found a greater incidence of complications in chronic injury cohorts, while there was no difference in revision rates. There may be several reasons for why chronic cases experienced a greater rate of complications. First, chronic patients typically have more scar tissue and bone callus, making the arthroscopic dissection more difficult. Second, chronic cases are performed with graft reconstruction, which is a more involved procedure than acute fixation, requiring more dissection and a longer operative time. Additionally, grafting itself has inherent risk, since autografts are associated with donor site morbidity and allografts carry an inherent infection risk. When comparing the types of complications experienced, chronic cases appeared to have greater rates of hardware failure, while acute injuries more frequently experienced recurrent instability.

In our pooled analysis, there appeared to be little differences between acute and chronic injury cohorts in postoperative scores for several outcomes, such as the ASES, CMS, SF-36 (physical and mental components), and Taft score. However, pooled scores for the chronic cohorts in SSV, UCLA Shoulder score, and VAS appeared to be worse overall than for acute counterparts. It must be noted that this finding is only based on a descriptive interpretation of the data, as there were not enough studies to identify statistically significant differences. Our subanalysis is also limited by a lack of preoperative data to compare % improvements.

At final follow up after arthroscopic CC ligament reconstruction, coracoclavicular distances measured at rest ranged from 7.3 mm to 11.8 mm, showing marked improvement from preoperative values. In healthy individuals, the average distance between the clavicle and coracoid process ranges between 11 and 13 mm.37 Thus, arthroscopic CC ligament reconstruction was effective at restoring and maintaining coracoclavicular distances to within a normal range. However, loss of reduction (LOR) did occasionally occur and rates varied greatly between studies, potentially reflecting differences in the arthroscopic techniques utilized. Loss of reduction is among the most common complications after CC reconstruction. Lee et al. found that LOR after CC reconstruction was associated with prolonged duration between injury and treatment and poorer quality initial reduction.36 Additionally, the authors suggested that failed reduction is associated with a more medial position of clavicle tunnels. Other studies have similarly reported that more medial bone tunnels are associated with unsuccessful reduction after reconstruction.10,15,45,59 This emphasizes the importance of developing a clear visual field when working arthroscopically by removing any excess soft tissue and adequately visualizing your tunnel placement.

4.1

4.1 Strengths

To our knowledge, this systematic review is the first to comprehensively study clinical outcomes following arthroscopic CC ligament reconstruction. Our analysis included a large sample of 52 total studies, spanning a variety of arthroscopic techniques for CC ligament reconstruction across many institutions. A rigorous methodology was performed for study screening and analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.56

4.2

4.2 Limitations

This analysis has several limitations. Since arthroscopic CC reconstruction has gained interest relatively recently, the majority of studies include smaller samples and shorter follow-up timelines. There is also limited data regarding the learning curve of the procedure, and how results may vary as surgeons become more familiar with the technique. Additionally, several studies included in our analysis were early pioneers in arthroscopic CC reconstruction, and the techniques described may have been improved upon in recent years. Thus, the overall effect size of outcomes may potentially be underestimated in this study. Due to a limited number of studies reporting mean/standard deviation scores for most outcomes, our comparative analysis of postoperative scores between acute and chronic cases was limited to a descriptive analysis. There were insufficient papers reporting the same outcomes to allow for assessment of statistically significant differences between acute and chronic cases. Lastly, there are limited high quality directly comparative studies examining open versus arthroscopic CC ligament reconstruction to determine with confidence if one technique is superior.

5

5 Conclusions

This systematic review demonstrates that arthroscopic management of acute and chronic CC ligament injuries exceeds the MCID and PASS for a variety of clinical outcomes, with low failure rates. Arthroscopic CC reconstruction is a safe and effective alternative to open surgery for chronic AC joint dislocations. Future, high-quality randomized studies are needed to directly compare outcomes between open and arthroscopic surgery for CC ligament injury to determine superiority of one technique.

Guardian/patient consent

Not applicable.

Declarations of interest

Dr. Khan is a consultant for Arthrex and Bioventus, and receives research support from Arthrex and Smith+Nephew. Dr. Erickson is a consultant for Arthrex, and receives research support from Arthrex, DePuy, Linvatec, Stryker, and Smith+Nephew.

Ethics

Our study was IRB-exempt as it is a systematic review and evaluates only publicly available studies.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Rohan Shah: Conceptualization, Formal analysis, Investigation, Project administration, Visualization, Writing – original draft, preparation, Writing – review & editing. Chetan Gohal: Conceptualization, Methodology, Project administration, Supervision, Validation, Writing – original draft, preparation, Writing – review & editing. Mark Plantz: Data curation, Formal analysis, Investigation, Methodology, Software, Validation. Brandon J. Erickson: Supervision, Writing – review & editing. Moin Khan: Conceptualization, Methodology, Project administration, Supervision, Writing – original draft, preparation, Writing – review & editing. Vehniah Tjong: Conceptualization, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.

References

  1. , , , , , . Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tight rope: randomized comparative study of clinical outcome and cost-effectiveness. J Shoulder Elbow Surg. 2019;28(11):2090-2097.
    [Google Scholar]
  2. , , , , , . Acromioclavicular joint disruptions: a comparison of two surgical approaches ‘hook’ and ‘rope’. J Orthop Surg. 2018;26(1)
    [Google Scholar]
  3. , , . Acromioclavicular joint dislocations. Curr Rev Musculoskelet Med. 2014;7(1):33-39.
    [Google Scholar]
  4. , , , et al . Current concepts in the treatment of acromioclavicular joint dislocations. Arthroscopy. 2013;29(2):387-397.
    [Google Scholar]
  5. , , , , . Short-term outcomes of arthroscopic TightRope® fixation are better than hook plate fixation in acute unstable acromioclavicular joint dislocations. Eur J Orthop Surg Traumatol. 2018;28(5):869-875.
    [Google Scholar]
  6. , , , , , . All-arthroscopic reconstruction of severe chronic acromioclavicular joint dislocations. Arthroscopy. 2019;35(5):1324-1335.
    [Google Scholar]
  7. , , , , , . All-arthroscopic Weaver-Dunn- Chuinard procedure with double-button fixation for chronic acromioclavicular joint dislocation. Arthroscopy. 2010;26(2):149-160.
    [Google Scholar]
  8. , , , , , . The Kite technique: a new all- arthroscopic technique for the treatment of acute acromioclavicular joint dislocation. Knee Surg Sports Traumatol Arthrosc. 2021;29(7):2055-2063.
    [Google Scholar]
  9. , , , . The frequency of reduction loss after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device, and its effect on clinical and radiological results. J Orthop Surg Res. 2020;15(1):136.
    [Google Scholar]
  10. , , . The anatomic coracoclavicular ligament reconstruction: surgical technique and indications. J Shoulder Elbow Surg. 2010;19(2 Suppl):37-46.
    [Google Scholar]
  11. , , , , , , . Arthroscopic fixation for acute acromioclavicular joint disruption using the TightRope device. J Orthop Surg. 2015;23(3):309-314.
    [Google Scholar]
  12. , , , . Arthroscopic reconstruction of the acromioclavicular joint disruption: surgical technique and preliminary results. Arch Orthop Trauma Surg. 2006;126(9):575-581.
    [Google Scholar]
  13. , , . Prevalence of remaining horizontal instability in high-grade acromioclavicular joint injuries surgically managed. Eur J Orthop Surg Traumatol. 2017;27(3):323-333.
    [Google Scholar]
  14. , , , et al . Complication rates and types of failure after arthroscopic acute acromioclavicular dislocation fixation. Prospective multicenter study of 116 cases. Orthop Traumatol Surg Res. 2015;101(8 Suppl):S313-S316.
    [Google Scholar]
  15. , , , , , , . Early failures with single clavicular transosseous coracoclavicular ligament reconstruction. J Shoulder Elbow Surg. 2012;21(12):1746-1752.
    [Google Scholar]
  16. , , . Functional and radiological outcome after arthroscopic and open acromioclavicular stabilization using a double-button fixation system. Acta Orthop Belg. 2010;76(5):585-591.
    [Google Scholar]
  17. , , , et al . Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. J Am Acad Orthop Surg Glob Res Rev. 2018;2(3)
    [Google Scholar]
  18. , , , , , . The learning curve for the Latarjet procedure: a systematic review. Orthop J Sports Med. 2018;6(7)
    [Google Scholar]
  19. , , , , . Subacromial morphometric assessment of the clavicle hook plate. Injury. 2010;41(6):613-619.
    [Google Scholar]
  20. , . Evaluation of arthroscopic stabilization of acute acromioclavicular joint dislocation using the TightRope system. Orthopedics. 2012;35(1):e18-e22.
    [Google Scholar]
  21. , , , , , . Comparing mini-open and arthroscopic acromioclavicular joint repair: functional results and return to sport. Musculoskelet Surg. 2016;100(3):187-191.
    [Google Scholar]
  22. , , . Acromioclavicular joint injuries. . 2005;vol. 2:1332-1364.
    [Google Scholar]
  23. , , , , , . Combined arthroscopically assisted coraco- and acromioclavicular stabilization of acute high-grade acromioclavicular joint separations. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):212-220.
    [Google Scholar]
  24. , , , , , , . Arthroscopic coracoclavicular ligament reconstruction for acromioclavicular joint dislocation. J Nippon Med Sch. 2018;85(3):166-171.
    [Google Scholar]
  25. , , , et al . The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343
    [Google Scholar]
  26. , , , , , . Arthroscopically assisted reduction of acute acromioclavicular joint dislocation using a single double-button device: medium- term clinical and radiological outcomes. Orthop Traumatol Surg Res. 2018;104(1):33-38.
    [Google Scholar]
  27. , , , , , . Arthroscopically assisted stabilization of chronic AC-joint instabilities in GraftRope™ technique with an additive horizontal tendon augmentation. Arch Orthop Trauma Surg. 2013;133(6):841-851.
    [Google Scholar]
  28. , , , . Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003;4(7):407-414.
    [Google Scholar]
  29. , , , , , . 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. 2014;22(2):422-430.
    [Google Scholar]
  30. , , , et al . Anatomic ligament consolidation of the superior acromioclavicular ligament and the coracoclavicular ligament complex after acute arthroscopically assisted double coracoclavicular bundle stabilization. Knee Surg Sports Traumatol Arthrosc. 2019;27(10):3168-3179.
    [Google Scholar]
  31. , , . Treatment of Rockwood type III acromioclavicular joint dislocation. Clin Shoulder Elb. 2018;21(1):48-55.
    [Google Scholar]
  32. , , , , , . Primary versus revision arthroscopically-assisted acromio- and coracoclavicular stabilization of chronic AC-joint instability. Arch Orthop Trauma Surg. 2019;139(8):1101-1109.
    [Google Scholar]
  33. , , , , . Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations in a coracoclavicular Double-TightRope technique: V-shaped versus parallel drill hole orientation. Arch Orthop Trauma Surg. 2013;133(10):1431-1440.
    [Google Scholar]
  34. , , , , , . Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery. J Shoulder Elbow Surg. 2013;22(12):1650-1655.
    [Google Scholar]
  35. , , , et al . Arthroscopic- assisted coracoclavicular ligament reconstruction: clinical outcomes and return to activity at mean 6-year follow-up. Arthroscopy. 2021;37(4):1086-1095.e1.
    [Google Scholar]
  36. , , , , , , . Arthroscopically assisted coracoclavicular fixation using a single flip button device technique: what are the main factors affecting the maintenance of reduction? BioMed Res Int. 2017;2017
    [Google Scholar]
  37. , , , , , . What role do plain radiographs have in assessing the skeletally immature acromioclavicular joint? Clin Orthop Relat Res. 2014;472(1):284-293.
    [Google Scholar]
  38. , , , et al . Arthroscopic coracoclavicular fixation using multiple low-profile devices in acute acromioclavicular joint dislocation. Arthroscopy. 2019;35(1):14-21.
    [Google Scholar]
  39. , , , . Coracoclavicular ligament reconstruction: a systematic review and a biomechanical study of a triple endobutton technique. Medicine (Baltim). 2014;93(28)
    [Google Scholar]
  40. , , , , , . Clinical outcome of a modified coracoid tunnel-free coracoclavicular sling technique with remnant preservation for the treatment of high-grade acromioclavicular joint separation: a report of 48 cases with 2 to 5 Years of follow-up. Am J Sports Med. 2021;49(6):1612-1618.
    [Google Scholar]
  41. , , . Intraoperative and postoperative complications after arthroscopic coracoclavicular stabilization. Clin Orthop Surg. 2019;11(1):103-111.
    [Google Scholar]
  42. , , , . Arthroscopic treatment of acute acromioclavicular joint dislocation by coracoclavicular ligament augmentation. Knee Surg Sports Traumatol Arthrosc. 2015;23(5):1460-1466.
    [Google Scholar]
  43. , , , et al . Arthroscopic treatment of acute acromioclavicular dislocations using a double button device: clinical and MRI results. Orthopaedics & traumatology, surgery & research : OTSR. 2015;101(8):895-901.
    [Google Scholar]
  44. , , , , , , . Quantifying the minimal and substantial clinical benefit of the Constant-Murley score and the Disabilities of the Arm, Shoulder and Hand score in patients with calcific tendinitis of the rotator cuff. JSES Int. 2020;4(3):606-611.
    [Google Scholar]
  45. , , , , , . High Early-onset acromioclavicular secondary pathologies after acute arthroscopic joint reduction: a cohort study. Arch Orthop Trauma Surg. 2022;142(7):1623-1631.
    [Google Scholar]
  46. , , , , , , . A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med. 2006;34(2):236-246.
    [Google Scholar]
  47. , , , et al . Defining minimal clinically important difference and patient acceptable symptom state after the Latarjet procedure. Am J Sports Med. 2022;50(10):2761-2766.
    [Google Scholar]
  48. , , , , . Arthroscopic acromioclavicular joint reconstruction using knotless coracoclavicular fixation and soft-tissue anatomic coracoclavicular ligament reconstruction. Arthrosc Tech. 2017;6(1):e37-e42.
    [Google Scholar]
  49. , , , , , , . Complications related to anatomic reconstruction of the coracoclavicular ligaments. Am J Sports Med. 2012;40(7):1628-1634.
    [Google Scholar]
  50. , , , , . Arthroscopic reconstruction after acute acromioclavicular separation injuries. JBJS Essent Surg Tech. 2017;7(1):e7.
    [Google Scholar]
  51. , , , et al . Acromioclavicular and coracoclavicular ligament reconstruction for acromioclavicular joint instability: a systematic review of clinical and radiographic outcomes. Arthroscopy. 2018;34(6):1979-1995.
    [Google Scholar]
  52. , , , , , , . Arthroscopic treatment of acute acromioclavicular joint dislocation with double flip button. Knee Surg Sports Traumatol Arthrosc. 2009;17(12):1511-1515.
    [Google Scholar]
  53. , , , , , , . BiPOD arthroscopically assisted bidirectional stabilisation technique for high-grade acromioclavicular joint injury: two-year clinical and radiological outcomes. Arch Orthop Trauma Surg. 2021;141(9):1559-1565.
    [Google Scholar]
  54. , , . Comparison of clinical efficacy between arthroscopically assisted Tight-Rope technique and clavicular hook plate fixation in treating acute high-grade acromioclavicular joint separations. J Orthop Surg. 2021;29(2)
    [Google Scholar]
  55. , , , , , , . Mid-term outcomes of arthroscopically-assisted anatomic coracoclavicular ligament reconstruction using tendon allograft for high-grade acromioclavicular joint dislocations. Arthroscopy. 2021;37(10):3025-3035.
    [Google Scholar]
  56. , , , et al . The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.
    [Google Scholar]
  57. , , , , . Outcome after arthroscopic reconstruction of the coracoclavicular ligaments using a double-bundle coracoid cerclage technique. Arthroscopy. 2015;31(10):1933-1940.
    [Google Scholar]
  58. , , , , , , . Arthroscopically assisted 2-bundle anatomical reduction of acute acromioclavicular joint separations. Am J Sports Med. 2010;38(6):1179-1187.
    [Google Scholar]
  59. , , , , . Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations. Am J Sports Med. 2011;39(7):1507-1516.
    [Google Scholar]
  60. , , , , . Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations. Am J Sports Med. 2011;39(7):1507-1516.
    [Google Scholar]
  61. , , , , . Arthroscopically assisted coracoclavicular ligament reconstruction for chronic acromioclavicular joint instability. Arch Orthop Trauma Surg. 2008;128(11):1327-1333.
    [Google Scholar]
  62. , , , , . Coracoid clavicular tunnel angle is related with loss of reduction in a single-tunnel coracoclavicular fixation using a dog bone button in acute acromioclavicular joint dislocation. Knee Surg Sports Traumatol Arthrosc. 2019;27(12):3835-3843.
    [Google Scholar]
  63. , , , . Arthroscopic-Assisted coracoclavicular ligament reconstruction for acute acromioclavicular dislocation using 2 clavicular and 1 coracoid cortical fixation buttons with suture Tapes. Arthroscopy. 2017;33(8):1458-1466.
    [Google Scholar]
  64. , , . Complications after arthroscopic coracoclavicular reconstruction using a single adjustable-loop-length suspensory fixation device in acute acromioclavicular joint dislocation. Arthroscopy. 2015;31(5):816-824.
    [Google Scholar]
  65. , , , . Early failure of coracoclavicular ligament reconstruction using TightRope system. Acta Orthop Belg. 2016;82(1):119-123.
    [Google Scholar]
  66. , , , , , , . Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712-716.
    [Google Scholar]
  67. , , , et al . Stabilization of acute high-grade acromioclavicular joint separation: a prospective assessment of the clavicular hook plate versus the double double-button suture procedure. Am J Sports Med. 2018;46(11):2725-2734.
    [Google Scholar]
  68. , , , . Dislocation of the acromioclavicular joint. An end-result study. J Bone Joint Surg Am. 1987;69(7):1045-1051.
    [Google Scholar]
  69. , , . Arthroscopic procedures and therapeutic results of anatomical reconstruction of the coracoclavicular ligaments for acromioclavicular Joint dislocation. Orthop Traumatol Surg Res. 2016;102(5):583-587.
    [Google Scholar]
  70. , , , , . Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease. J Shoulder Elbow Surg. 2009;18(6):927-932.
    [Google Scholar]
  71. , , , et al . Minimal clinically important differences in the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores after arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2020;29(7):1406-1411.
    [Google Scholar]
  72. , , , , , , . Arthroscopic stabilization of chronic acromioclavicular joint dislocations: triple- versus single-bundle reconstruction. Am J Sports Med. 2016;44(2):482-489.
    [Google Scholar]
  73. , , , , , , . Arthroscopically assisted acromioclavicular joint stabilization leads to significant clavicular tunnel widening in the early post-operative period. Knee Surg Sports Traumatol Arthrosc. 2019;27(12):3821-3826.
    [Google Scholar]
  74. , , , , , . Reliability and validity of shoulder function outcome measures in people with a proximal humeral fracture. Disabil Rehabil. 2014;36(13):1072-1079.
    [Google Scholar]
  75. , , . Learning curve in the arthroscopic Latarjet procedure: an analysis of the first 171 cases. J Orthop. 2023;50:58-64.
    [Google Scholar]
  76. , , , . Curva de aprendizaje en la cirugía artroscópica de cadera [Learning curve of arthroscopic hip surgery] Acta Ortop Mex. 2010;24(3):177-181.
    [Google Scholar]
  77. , , , et al . Additional acromioclavicular cerclage limits lateral tilt of the scapula in patients with arthroscopically assisted coracoclavicular ligament reconstruction. Arch Orthop Trauma Surg. 2021;141(8):1331-1338.
    [Google Scholar]

Fulltext Views
339

PDF downloads
47
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections

Suggested read for related articles: