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Editorial Commentary: Acute Repair of the Acromioclavicular Joint Capsule and Ligaments and Deltotrapezial Fascia Could Allow Biological Healing of High-Grade Acromioclavicular Separation—Coracoclavicular Ligament Graft Augmentation Could Be Indicated if Time to Surgery Is Greater Than 3 Weeks

      Abstract

      Surgical management of chronic acromioclavicular joint (ACJ) dislocations is a matter of controversy. In the acute setting of high-grade acromioclavicular separation, if a surgical repair of the ACJ capsule and ligaments and deltotrapezial fascia could allow biological healing of the ligaments themselves, this could be enough to restore the functional biomechanics of the joint; unfortunately, this is not true for chronic cases. In the latter situation, a surgical technique using biological augmentation such as autograft or allograft should be preferred. Time is very important for this injury, and a chronic lesion should be considered when treatment is being performed 3 weeks after trauma. The graft should be passed around the base of the coracoid or through a tunnel at the base of the coracoid itself and then at the level of the clavicle as anatomically possible to reproduce the function of the native ligaments. However, some studies have shown that passing the graft at the base of the coracoid and wrapping it around the clavicle could also achieve satisfactory outcomes. An arthroscopic technique, when used in combination, could be great to treat the associated lesions, which have a reported percentage between 30% and 49%. Finally, to restore the biomechanics of the ACJ, however, reconstruction of the acromioclavicular superior and posterior capsules together with the deltotrapezial fascia seems to be very important.
      Treating chronic acromioclavicular joint (ACJ) dislocations is a very challenging task for orthopaedic surgeons. Many techniques have been described, but the gold standard has not been determined.
      In the past, Weaver and Dunn
      • Weaver J.K.
      • Dunn H.K.
      Treatment of acromioclavicular injuries, especially complete acromioclavicular separation.
      described a surgical procedure that became very popular; this technique consisted of excision of the distal third of the clavicle, detachment of the acromioclavicular (AC) ligament from the acromion, and transposition of this ligament to the distal third of the clavicle. This procedure has been used for a long time; however, numerous failures in term of recurrent instability have been described thereafter, such as in the study of Weinstein et al.
      • Weinstein D.M.
      • McCann P.D.
      • McIlveen S.J.
      • Flatow E.L.
      • Bigliani L.U.
      Surgical treatment of complete acromioclavicular dislocations.
      More recently, Boileau et al.
      • Boileau P.
      • Gastaud J.O.
      • Brassart N.
      • Roussane Y.
      All-arthroscopic Weaver-Dunn-Chuinard procedure with double-button fixation for chronic acromioclavicular joint dislocation.
      have described an arthroscopy-assisted version of the aforementioned technique and, furthermore, attempted to improve the results, augmenting the repair with the use of a titanium compression coracoclavicular (CC) button.
      The Weaver-Dunn technique and its variants, however, have another potential problem related to sacrifice of the coracoacromial ligament that could destroy the coracoacromial arch continuity with potential consequences particularly in patients with massive rotator cuff tears. In recent years, biomechanical and clinical studies have focused on the anatomic reconstruction of the CC ligaments through synthetic, autograft, or allograft tissue. At the beginning, these procedures were described using open techniques, but more recently, arthroscopy-assisted techniques have been proposed.
      In the current study, entitled “Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up,” Lamplot, Shah, Chan, Hancock, Gentile, Rodeo, Allen, Williams, Altchek, Dines, Warren, Cordasco, Gulotta, and Dines
      • Lamplot J.D.
      • Shah S.S.
      • Chan J.M.
      • et al.
      Arthroscopic-assisted coracoclavicular ligament reconstruction: Clinical outcomes and return to activity at mean 6-year follow-up.
      report clinical and functional outcomes at a mean of 6-years follow-up in patients treated with arthroscopy-assisted CC ligament reconstruction. In particular, this study presents a series of 88 patients in whom CC reconstruction was performed using different soft-tissue grafts (allograft or autograft according to surgeon preference) and variable times (acute or chronic) after index trauma. In this study, 30 days was considered the timing to differentiate acute from chronic trauma.
      The debate on the definition of the time of chronicity is ongoing in the literature. Muench et al.,
      • Muench L.N.
      • Kia C.
      • Jerliu A.
      • et al.
      Functional and radiographic 514 outcomes after anatomic coracoclavicular ligament reconstruction for type III/V acromioclavicular joint injuries.
      in their study, proposed a threshold of 6 months for terming ACJ injuries as chronic. In our experience, this time threshold should really differentiate whether the possibility still exists to treat the lesion with surgical procedures that rely on the biological capacity of the ligaments to heal without the use of synthetic or biological support such as soft-tissue graft (autograft or allograft). On the basis of a literature review by Flint et al.,
      • Flint J.H.
      • Wade A.M.
      • Giuliani J.
      • Rue J.P.
      Defining the terms acute and chronic in orthopedic sports injuries: A systematic review.
      we believe that the limit for this time should be 3 weeks.
      This is a crucial point because it means that we need to identify, as soon as possible, through clinical examinations and specific radiographic views, which patients are at risk of failure of conservative management. This is particular important for patients presenting with a type III separation, which we know is well treated with conservative management in an average of 80% of cases. We need to identify the patients at risk of failure so that more aggressive treatment can be offered early. The use of biological supports such as tendon or graft, at least if there are not specific considerations discussed with the patients, in our opinion could potentially represent an over-treatment if the surgical procedure is performed within the first 3 weeks after trauma.
      In the case series reported by Lamplot et al.,
      • Lamplot J.D.
      • Shah S.S.
      • Chan J.M.
      • et al.
      Arthroscopic-assisted coracoclavicular ligament reconstruction: Clinical outcomes and return to activity at mean 6-year follow-up.
      the tendon in all cases was passed around the base of the coracoid without any tunnels; however, it was secured in different ways at the level of the clavicle. Although there are some concerns about the possibility of healing of tissue graft around the coracoid base without any fixation, we could eliminate the risk of coracoid complications in this way. Spiegl et al.
      • Spiegl U.J.
      • Smith S.D.
      • Euler S.A.
      • Dornan G.J.
      • Millett P.J.
      • Wijdicks C.A.
      Biomechanical consequences of coracoclavicular reconstruction techniques on clavicle strength.
      reported the possibility of coracoid fractures associated with drilled tunnels in the coracoid bone during an ACJ reconstruction technique. On the other side, at the level of the clavicle, the graft was secured through 1 tunnel or 2 tunnels or was just wrapped around the clavicle itself. The authors did not report differences in terms of clinical and radiologic outcomes between the 3 techniques. In light of the reported outcomes, we could ask, Should a really anatomic ACJ reconstruction be performed? It seems that the use of biological support fixing the coracoid and clavicle together could achieve functional biomechanics of the ACJ independently of the fact that a really anatomic reconstruction is performed. Furthermore, the fact that no holes are drilled in the clavicular bone could avoid complications such as fracture through the holes. Spiegl et al. showed that large bone tunnels may predispose patients to clavicle fracture after anatomic CC reconstruction. To reduce this complication, when an anatomic reconstruction is performed at the level of the clavicle, the 2 drill holes should be well spaced and have a diameter inferior to 5 mm.
      • Spiegl U.J.
      • Smith S.D.
      • Euler S.A.
      • Dornan G.J.
      • Millett P.J.
      • Wijdicks C.A.
      Biomechanical consequences of coracoclavicular reconstruction techniques on clavicle strength.
      Another key point is the problem related to the persistence of anteroposterior instability in patients with ACJ injury. During the past few decades, a substantially growing scientific interest in the AC capsule and ligaments has been observed. Dyrna et al.
      • Dyrna F.G.E.
      • Imhoff F.B.
      • Voss A.
      • et al.
      The integrity of the acromioclavicular capsule ensures physiological centering of the acromioclavicular joint under rotational loading.
      noted a synergistic contribution of the CC and AC capsular structures to ACJ stability. This synergy supported the idea that to achieve an anatomic reconstruction of the ACJ after injury, both structures should be addressed during surgery. Hislop et al.,
      • Hislop P.
      • Sakata K.
      • Ackland D.C.
      • Gotmaker R.
      • Evans M.C.
      Acromioclavicular joint stabilization: A biomechanical study of bidirectional stability and strength.
      in a laboratory study, noted further evidence of the importance of the ACJ capsule and associated soft tissue in affording horizontal joint instability.
      Numerous studies and techniques have focused on the isolated reconstruction of the CC ligamentous complex, with reported radiographic failures in up to 35% of cases; moreover, Stucken and Cohen
      • Stucken C.
      • Cohen S.B.
      Management of acromioclavicular joint injuries.
      reported, in particular, a high recurrence of anteroposterior instability of up to 43%. These data highlight the importance of the AC ligament and the superior element of the ACJ that is reinforced by fibers of the deltotrapezial fascia, as shown by Ha et al.
      • Ha A.S.
      • Petscavage-Thomas J.M.
      • Tagoylo G.H.
      Acromioclavicular joint: The other joint in the shoulder.
      Beitzel and Mazzocca
      • Beitzel K.
      • Mazzocca A.D.
      Open anatomic reconstruction of chronic acromioclavicular instability.
      reported that persistent postsurgical anteroposterior instability is the only factor that may adversely affect the clinical outcomes. For this reason, reconstructive strategies must give the same importance to AC reconstruction as to CC reconstruction. This evidence could explain why despite reports of some loss of reduction in the vertical plane after CC reconstruction, patients still have good subjective outcomes, particularly when clinical examination findings show that the ACJ posterior translation test result is negative, as reported by Garofalo et al.,
      • Garofalo R.
      • Ceccarelli E.
      • Castagna A.
      • et al.
      Open capsular and ligament reconstruction with semitendinosus hamstring autograft successfully controls superior and posterior translation for type V acromioclavicular joint dislocation.
      as well as the literature review by Gowd et al.
      • Gowd A.K.
      • Liu J.N.
      • Cabarcas B.C.
      • et al.
      Current concepts in the operative management of acromioclavicular dislocations: A systematic review and meta-analysis of operative techniques.
      Lamplot et al.
      • Lamplot J.D.
      • Shah S.S.
      • Chan J.M.
      • et al.
      Arthroscopic-assisted coracoclavicular ligament reconstruction: Clinical outcomes and return to activity at mean 6-year follow-up.
      failed to show better results in patients in whom reconstruction of the AC capsule and ligaments was associated with CC reconstruction. However, looking at their series shows that the 8% of cases that were not able to resume activity fell into the group that did not receive any associated AC reconstruction. In consequence, we can argue that if a really anatomic reconstruction of the CC ligaments is not also performed, the ACJ and superior capsule should be correctly evaluated and addressed to improve the results of surgery for ACJ injuries.
      A last important point regarding the study by Lamplot et al.
      • Lamplot J.D.
      • Shah S.S.
      • Chan J.M.
      • et al.
      Arthroscopic-assisted coracoclavicular ligament reconstruction: Clinical outcomes and return to activity at mean 6-year follow-up.
      is related to the use of arthroscopy when performing ACJ reconstruction. When we look at outcomes previously reported with open procedures, shifting to arthroscopy does not appear to provide significant improvement. However, Lamplot et al., similar to Boileau et al.,
      • Boileau P.
      • Gastaud O.
      • Wilson A.
      • Trojani C.
      • Bronsard N.
      All arthroscopic reconstruction of severe chronic acromioclavicular joint dislocations.
      reported that the percentage of associated lesions, mostly intra-articular, that were treated at the time of the ACJ procedure was 49%. In light of the reported results, should we really treat all the ACJ disruptions using an arthroscopic-assisted technique?
      If “data are data,” the answer is that we cannot recommend that ACJ reconstruction procedures should be performed arthroscopically for this reason. Nevertheless, we can suggest that before undergoing surgery, patients with an AC injury should undergo magnetic resonance imaging to exclude associated lesions that need surgical management, and of course, arthroscopy could represent a very useful tool in very experienced hands.
      However, in the management of chronic ACJ instability, the open approach remains important to guarantee that there is no interposition of the deltotrapezial fascia between the clavicle and the acromion. Natera et al.,
      • Natera L.
      • Sarasquete Reiriz J.
      • Abat F.
      Anatomic reconstruction of chronic coracoclavicular ligament tears: Arthroscopic-assisted approach with nonrigid mechanical fixation and graft augmentation.
      in their article reporting on arthroscopy-assisted ACJ reconstruction, recommended that once anatomic reduction of the ACJ has been reached, the deltotrapezial fascia should be carefully reconstructed to ensure adequate vertical and horizontal stability.
      In conclusion, in our opinion, many points are not clearly defined for the treatment of AC separation, but we believe that increasing knowledge of the anatomy and biomechanics, associated with surgeons’ experience coming from results in the literature, could help to define the diagnosis and allow better treatment of ACJ injuries without neglecting careful preoperative imaging to define potentially associated lesions and select the most suitable approach.

      Supplementary Data

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