title: Bilateral weighted radiographs are required for accurate classification of acromioclavicular separation: an observational study of 59 cases.
abstract: BACKGROUND
  Misinterpretation of the Rockwood classification system for acromioclavicular joint (ACJ) separations has resulted in a trend towards using unilateral radiographs for grading. Further, the use of weighted views to 'unmask' a grade III injury has fallen out of favour. Recent evidence suggests that many radiographic grade III injuries represent only a partial injury to the stabilising ligaments. This study aimed to determine (1) whether accurate classification is possible on unilateral radiographs and (2) the efficacy of weighted bilateral radiographs in unmasking higher-grade injuries.
  
  
  METHODS
  Complete bilateral non-weighted and weighted sets of radiographs for patients presenting with an acromioclavicular separation over a 10-year period were analysed retrospectively, and they were graded I-VI according to Rockwood's criteria. Comparison was made between grading based on (1) a single antero-posterior (AP) view of the injured side, (2) bilateral non-weighted views and (3) bilateral weighted views. Radiographic measurements for cases that changed grade after weighted views were statistically compared to see if this could have been predicted beforehand.
  
  
  RESULTS
  Fifty-nine sets of radiographs on 59 patients (48 male, mean age of 33 years) were included. Compared with unilateral radiographs, non-weighted bilateral comparison films resulted in a grade change for 44 patients (74.5%). Twenty-eight of 56 patients initially graded as I, II or III were upgraded to grade V and two of three initial grade V patients were downgraded to grade III. The addition of a weighted view further upgraded 10 patients to grade V. No grade II injury was changed to grade III and no injury of any severity was downgraded by a weighted view. Grade III injuries upgraded on weighted views had a significantly greater baseline median percentage coracoclavicular distance increase than those that were not upgraded (80.7% vs. 55.4%, p=0.015). However, no cut-off point for this value could be identified to predict an upgrade.
  
  
  CONCLUSIONS
  The accurate classification of ACJ separation requires weighted bilateral comparative views. Attempts to predict grade on a single AP radiograph result in a gross underestimation of severity. The value of bilateral weighted views is to 'unmask' a grade V injury, and it is recommended as a first-line investigation.
authors.affiliation: Department of Trauma and Orthopaedics, Charing Cross Hospital, London, UK. Electronic address: edward.ibrahim@uclmail.net.
authors.forename: E F
authors.initials: EF
authors.lastname: Ibrahim
authors.affiliation: Department of Trauma and Orthopaedics, Charing Cross Hospital, London, UK.
authors.forename: N P
authors.initials: NP
authors.lastname: Forrest
authors.affiliation: Department of Trauma and Orthopaedics, Charing Cross Hospital, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Forester
mesh_terms: D000173:Acromioclavicular Joint / Q000293:injuries / Q000473:pathology*; D000328:Adult; D002968:Clavicle / Q000293:injuries / Q000473:pathology*; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis* / Q000473:pathology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D017410:Practice Guidelines as Topic; D015203:Reproducibility of Results; D012540:Scapula / Q000293:injuries / Q000473:pathology*; D014057:Tomography, X-Ray Computed; D015599:Trauma Severity Indices
keywords: ACJ; Acromioclavicular; Classification; Dislocation; Injury; MRI; Rockwood; Separation; Weight bearing; Weighted