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Editorial Commentary: Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction Leads to Improved Patient-Reported Outcomes, But Patient Satisfaction Is a Harder Threshold to PASS

      Abstract

      There are numerous described techniques for surgical management of high-grade acromioclavicular (AC) joint injuries, and the associated clinical outcomes can be quite variable. Contemporary techniques are typically directed at anatomic reconstruction of the coracoclavicular (CC) ligaments through either an arthroscopy-assisted or an open approach. Most patients treated with acute surgery improve, whereas in chronic cases, the majority improve, but a significant number have persistent recurrent deformity due to loss of anatomic reduction. In addition, whether acute or chronic, over one quarter of patients do not have a PASS (patient acceptable symptomatic state). Of interest, PASS may not primarily be related to the final deformity in terms of coracoclavicular distance, and investigation is still required in terms of the effect of anteroposterior or rotational instability of the AC joint after injury and surgery. Finally, PASS values for AC separation are not well established, resulting in a current limitation of the strength of applying threshold values to this pathology.
      Surgical management of acromioclavicular (AC) joint injuries has been a topic of debate for more than a century.
      • Galatz L.
      • Hollis Jr., R.
      • Williams Jr., G.
      Acromioclavicular joint injuries.
      In Arthroscopy Techniques alone, there are 37 published techniques on this topic since 2012. Initial methods to restore AC joint stability described transfer of the coracoacromial ligament to the distal clavicle (i.e., Weaver-Dunn procedure), while more modern techniques focus on more anatomic reconstructions of the coracoclavicular (CC) ligaments through either open or arthroscopic-assisted approaches.
      • Galatz L.
      • Hollis Jr., R.
      • Williams Jr., G.
      Acromioclavicular joint injuries.
      ,
      • Frank R.M.
      • Cotter E.J.
      • Leroux T.S.
      • Romeo A.A.
      Acromioclavicular joint injuries: Evidence-based treatment.
      Results of arthroscopy-assisted CC reconstruction have, thus far, been promising, with high rates of patient satisfaction and improved patient-reported outcome scores (PRO scores) after surgery,
      • 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.
      • Ranne J.O.
      • Kainonen T.U.
      • Lehtinen J.T.
      • et al.
      Arthroscopic coracoclavicular ligament reconstruction of chronic acromioclavicular dislocations using autogenous semitendinosus graft: A two-year follow-up study of 58 patients.
      • Muench L.N.
      • Kia C.
      • Jerliu A.
      • et al.
      Functional and radiographic outcomes after anatomic coracoclavicular ligament reconstruction for type III/V acromioclavicular joint injuries.
      • Mori D.
      • Yamashita F.
      • Kizaki K.
      • Funakoshi N.
      • Mizuno Y.
      • Kobayashi M.
      Anatomic coracoclavicular ligament reconstruction for the treatment of acute acromioclavicular joint dislocation: Minimum 10-year follow-up.
      albeit with residual risk of recurrent deformity due to loss of anatomic reduction.
      In their study entitled “Mid-Term Outcomes of Arthroscopically Assisted Anatomic Coracoclavicular Ligament Reconstruction Using Tendon Allograft for High-Grade Acromioclavicular Joint Dislocations,” Nolte, Ruzbarsky, Elrick, Woolson, Midtgaard, and Millet report their experience treating acute and chronic high-grade acromioclavicular joint injuries in 102 patients with minimum 2-year follow-up.
      • Nolte P.C.
      • Ruzbarsky J.J.
      • Elrick B.P.
      • Woolson T.
      • Midtgaard K.S.
      • Millett P.J.
      Mid-term outcomes of arthroscopically-assisted anatomic coracoclavicular ligament reconstruction using tendon allograft for high-grade acromioclavicular joint dislocations.
      The mean overall coracoclavicular distance (CCD) improved significantly with surgical treatment (18.6 mm, 10.4 mm; P < .001). At a mean of 4.7-year follow-up, all patient-reported outcome measures improved significantly from preoperative values. Median patient satisfaction and postoperative American Shoulder and Elbow Surgeons (ASES) score were 9 (out of 10) and 96.6, respectively, the latter of which approximates healthy individuals without a history of shoulder problems (96.7).
      • McLean J.M.
      • Awwad D.
      • Lisle R.
      • Besanko J.
      • Shivakkumar D.
      • Leith J.
      An international, multicenter cohort study comparing 6 shoulder clinical scores in an asymptomatic population.
      Furthermore, 79.6% of patients met the minimal clinically important difference (MCID) for ASES as the primary outcome measure.
      An important component of the present study is a comparison between outcomes of CC reconstructions performed for acute and chronic injuries, with 6 weeks serving as the defining threshold. In the acute scenario, median postoperative CCD was 3.2 mm lower and more closely approximated the anatomic distance reported for uninjured controls.
      • Millett P.J.
      • Horan M.P.
      • Warth R.J.
      Two-year outcomes after primary anatomic coracoclavicular ligament reconstruction.
      When compared with chronic injuries, patients treated acutely also had higher rates of meeting MCID (100% vs. 64.5%; P < .001). However, there were no differences between the acute and chronic groups with respect to rates of achieving the patient-acceptable symptom state (PASS) (75.9% vs 70.0%; P = .786). As the authors indicate, this suggests that acute treatment may lead to a greater magnitude of improvement due to a more severe preoperative symptom state. However, acutely and chronically treated patients may end up at a similar level of function by mid-term follow-up, irrespective of anatomic or near-anatomic reduction.
      While there are meaningful improvements in PROs with arthroscopy-assisted CC reconstruction, only 72.5% of the total cohort reached PASS. This begs the inevitable question: Why are over a quarter of patients unable to achieve an acceptable standard? Nolte et al. did not find any differences in PASS percentage between acute and chronic injuries or between Rockwood Type III and IV/V injuries. Differences in CCD between acute and chronic cohorts were noted, but this did not translate to measurable differences in likelihood of achieving PASS. Distal clavicle resection was performed in nearly half of patients, but its effect on ultimate outcomes was not evaluated or controlled for. Additionally, revision rates were higher with clavicular interference screw fixation when compared to graft wrapping technique (22.6% vs 8.5%), without a specific analysis of the effect of these revisions on final outcome.
      One stone left unturned is the anteroposterior and rotational stability of the reconstruction. In the authors’ published technique, the acromioclavicular joint capsule is imbricated or repaired, but not formally reconstructed.
      • Menge T.J.
      • Tahal D.S.
      • Katthagen J.C.
      • Millett P.J.
      Arthroscopic acromioclavicular joint reconstruction using knotless coracoclavicular fixation and soft-tissue anatomic coracoclavicular ligament reconstruction.
      ,
      • Millett P.J.
      • Warth R.J.
      • Greenspoon J.A.
      • Horan M.P.
      Arthroscopically assisted anatomic coracoclavicular ligament reconstruction technique using coracoclavicular fixation and soft-tissue grafts.
      The capsule is known to be the primary restraint against posterior translation,
      • Frank R.M.
      • Cotter E.J.
      • Leroux T.S.
      • Romeo A.A.
      Acromioclavicular joint injuries: Evidence-based treatment.
      ,
      • Fukuda K.
      • Craig E.V.
      • An K.N.
      • Cofield R.H.
      • Chao E.Y.
      Biomechanical study of the ligamentous system of the acromioclavicular joint.
      whereas the distal clavicle excision may also exacerbate AP instability.
      • Beitzel K.
      • Sablan N.
      • Chowaniec D.M.
      • et al.
      Sequential resection of the distal clavicle and its effects on horizontal acromioclavicular joint translation.
      Cadaveric studies have demonstrated that the addition of an AC capsular augmentation can help restore horizontal stability.
      • Dyrna F.
      • Imhoff F.B.
      • Haller B.
      • et al.
      Primary stability of an acromioclavicular joint repair is affected by the type of additional reconstruction of the acromioclavicular capsule.
      ,
      • Morikawa D.
      • Huleatt J.B.
      • Muench L.N.
      • et al.
      Posterior rotational and translational stability in acromioclavicular ligament complex reconstruction: A comparative biomechanical analysis in cadaveric specimens.
      There is also some precedent for monitoring the anteroposterior reduction of the AC joint using postoperative CT scan.
      • Mori D.
      • Yamashita F.
      • Kizaki K.
      • Funakoshi N.
      • Mizuno Y.
      • Kobayashi M.
      Anatomic coracoclavicular ligament reconstruction for the treatment of acute acromioclavicular joint dislocation: Minimum 10-year follow-up.
      It is possible that failure to meet PASS was due to anteroposterior malreduction or persistent horizontal instability, but this was not formally measured.
      Another potential limitation stems from the threshold values used to determine rates of achieving PASS. In the present study, as well as the investigation by Muench et al.,
      • Muench L.N.
      • Kia C.
      • Jerliu A.
      • et al.
      Functional and radiographic outcomes after anatomic coracoclavicular ligament reconstruction for type III/V acromioclavicular joint injuries.
      the MCID, SCB, and PASS thresholds were extrapolated from patients undergoing rotator cuff repairs.
      • Cvetanovich G.L.
      • Gowd A.K.
      • Liu J.N.
      • et al.
      Establishing clinically significant outcome after arthroscopic rotator cuff repair.
      However, these populations are distinct in terms of age, activity level, and injury etiology. For instance, the median age of rotator cuff-injured patients has been previously reported as 59 years,
      • Khatri C.
      • Ahmed I.
      • Parsons H.
      • et al.
      The natural history of full-thickness rotator cuff tears in randomized controlled trials: A systematic review and meta-analysis.
      as compared with 45 years in the existing patient series. Additionally, while all AC separations are traumatic, only a percentage of rotator cuff tears can be attributed to a traumatic event.
      • Tan M.
      • Lam P.H.
      • Le B.T.
      • Murrell G.A.
      Trauma versus no trauma: an analysis of the effect of tear mechanism on tendon healing in 1300 consecutive patients after arthroscopic rotator cuff repair.
      Many rotator cuff tears are degenerative or occur in an acute-on-chronic setting.
      • Keener J.D.
      • Patterson B.M.
      • Orvets N.
      • Chamberlain A.M.
      Degenerative rotator cuff tears: Refining surgical indications based on natural history data.
      In other words, existing literature on AA-CC reconstruction extrapolates MCID, SCB, and PASS values for an older population with a degenerative condition to a younger population with an acute, traumatic injury. Establishment of threshold values specific to AC joint injuries would provide a better framework for interpreting outcomes after CC reconstruction, particularly as we consider the adjunctive role of concomitant AC joint reconstruction.
      Overall, the work by Nolte et al.
      • Nolte P.C.
      • Ruzbarsky J.J.
      • Elrick B.P.
      • Woolson T.
      • Midtgaard K.S.
      • Millett P.J.
      Mid-term outcomes of arthroscopically-assisted anatomic coracoclavicular ligament reconstruction using tendon allograft for high-grade acromioclavicular joint dislocations.
      should be commended for presenting a large cohort of patients treated with excellent mid-term results using modern techniques for arthroscopy-assisted CC reconstruction. Taken in sum, this procedure can reliably restore shoulder function to near-normal levels among individuals with high-grade AC joint injuries. However, there is a sizeable segment of the population that remains in an unacceptable symptom state, as defined by 27.5% failure to meet PASS values. We should continue to strive to improve our understanding of this procedure in order to restore an even greater percentage of patients to an acceptable level of pain and preinjury function.

      Supplementary Data

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