title: Is coracoclavicular stabilisation alone sufficient for the endoscopic treatment of severe acromioclavicular joint dislocation (Rockwood types III, IV, and V)?
abstract: BACKGROUND
  The primary objective was to evaluate correlations linking anatomical to functional outcomes after endoscopically assisted repair of acute acromioclavicular joint dislocation (ACJD).
  
  
  OBJECTIVE
  Combined acromioclavicular and coracoclavicular stabilisation improves radiological outcomes compared to coracoclavicular stabilisation alone.
  
  
  METHODS
  A prospective multicentre study was performed. Clinical outcome measures were pain intensity on a visual analogue scale (VAS), subjective functional impairment (QuickDASH score), and Constant's score. Anatomical outcomes were assessed on standard radiographs (anteroposterior view of the acromioclavicular girdle and bilateral axillary views) obtained preoperatively and postoperatively and on postoperative dynamic radiographs taken as described by Tauber et al.
  
  
  RESULTS
  Of 116 patients with acute ACJD included in the study, 48% had type III, 30% type IV, and 22% type V ACJD according to the Rockwood classification. Coracoclavicular stabilisation was achieved using a double endobutton in 93% of patients, and concomitant acromioclavicular stabilisation was performed in 50% of patients. The objective functional outcome was good, with an unweighted Constant's score ≥ 85/100 and a subjective QuickDASH functional disability score ≤ 10 in 75% of patients. The radiographic analysis showed significant improvements from the preoperative to the 1-year postoperative values in the vertical plane (decrease in the coracoclavicular ratio from 214 to 128%, p=10(-6)) and in the horizontal plane (decrease in posterior displacement from 4 to 0mm, p=5×10(-5)). The anatomical outcome correlated significantly with the functional outcome (absolute R value=0.19 and p=0.045). We found no statistically significant differences across the various types of constructs used. Intra-operative control of the acromioclavicular joint did not improve the result. Implantation of a biological graft significantly improved both the anatomical outcome in the vertical plane (p=0.04) and acromioclavicular stabilisation in the horizontal plane (p=0.02). The coracoclavicular ratio on the anteroposterior radiograph was adversely affected by a longer time from injury to surgery (p=0.02) and by a higher body mass index (BMI) (p=0.006). High BMI also had a negative effect on the difference in the distance separating the anterior edge of the acromion from the anterior edge of the clavicle between the injured and uninjured sides, as assessed on the axillary views (p=0.009).
  
  
  CONCLUSIONS
  This study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromioclavicular joint. Coracoclavicular stabilisation alone is not sufficient, regardless of the type of implant used. Implantation of a biological graft should be considered when the time from injury to surgery is longer than 10days. The weight of the upper limb should be taken into account, with 6weeks of immobilisation to unload the construct in patients who have high BMI values.
  
  
  METHODS
  II, prospective non-randomised comparative study.
authors.affiliation: Centre ostéo-articulaire des cèdres, parc Sud-Galaxie, 5, rue des Tropiques, Echirolles, France. Electronic address: jrhbarth@yahoo.fr.
authors.forename: J
authors.initials: J
authors.lastname: Barth
authors.affiliation: Centre hospitalier universitaire de Rouen, Rouen, France.
authors.forename: F
authors.initials: F
authors.lastname: Duparc
authors.affiliation: Centre ostéo-articulaire des cèdres, parc Sud-Galaxie, 5, rue des Tropiques, Echirolles, France.
authors.forename: K
authors.initials: K
authors.lastname: Andrieu
authors.affiliation: Médipôle Garonne, Toulouse, France.
authors.forename: M
authors.initials: M
authors.lastname: Duport
authors.affiliation: Clinique Générale d'Annecy, Annecy, France.
authors.forename: B
authors.initials: B
authors.lastname: Toussaint
authors.affiliation: Centre hospitalier universitaire de Rouen, Rouen, France.
authors.forename: S
authors.initials: S
authors.lastname: Bertiaux
authors.affiliation: Service de chirurgie de l'épaule et du coude, CCOM, CHRU de Strasbourg, Strasbourg, France.
authors.forename: P
authors.initials: P
authors.lastname: Clavert
authors.affiliation: Institut universitaire de l'appareil locomoteur et du sport, hôpital Pasteur 2, CHU de Nice, Nice, France.
authors.forename: O
authors.initials: O
authors.lastname: Gastaud
authors.affiliation: Clinique de Cagne-sur-Mer, Cagne-sur-Mer, France.
authors.forename: N
authors.initials: N
authors.lastname: Brassart
authors.affiliation: Centre hospitalier régional de Chambéry, Chambéry, France.
authors.forename: E
authors.initials: E
authors.lastname: Beaudouin
authors.affiliation: Médipôle de Savoie, Chambéry, France.
authors.forename: P
authors.initials: P
authors.lastname: De Mourgues
authors.affiliation: Clinique Kennedy, Montélimar, France.
authors.forename: D
authors.initials: D
authors.lastname: Berne
authors.affiliation: Clinique Générale d'Annecy, Annecy, France.
authors.forename: J
authors.initials: J
authors.lastname: Bahurel
authors.affiliation: Centre hospitalier universitaire de Rennes, Rennes, France.
authors.forename: N
authors.initials: N
authors.lastname: Najihi
authors.affiliation: Hôpital universitaire Xavier-Bichat, Paris, France.
authors.forename: P
authors.initials: P
authors.lastname: Boyer
authors.affiliation: Hôpital universitaire Ambroise-Paré, Boulogne-Billancourt, France.
authors.forename: B
authors.initials: B
authors.lastname: Faivre
authors.affiliation: CMC Paris V, Paris, France.
authors.forename: A
authors.initials: A
authors.lastname: Meyer
authors.affiliation: Chirurgie de l'épaule, groupe Maussins, 67, rue de Romainville, Paris, France.
authors.forename: G
authors.initials: G
authors.lastname: Nourissat
authors.affiliation: Polyclinique du Plateau, Bezons, France.
authors.forename: S
authors.initials: S
authors.lastname: Poulain
authors.affiliation: Hôpital privé de l'ouest parisien, Trappes, France.
authors.forename: F
authors.initials: F
authors.lastname: Bruchou
authors.affiliation: Unité biostatistique du CHU de Rouen, Rouen, France.
authors.forename: J F
authors.initials: JF
authors.lastname: Ménard
mesh_terms: D000173:Acromioclavicular Joint / Q000000981:diagnostic imaging / Q000293:injuries* / Q000503:physiopathology / Q000601:surgery; D000174:Acromion / Q000000981:diagnostic imaging / Q000601:surgery; D000208:Acute Disease; D000328:Adult; D000368:Aged; D001182:Arthroscopy / Q000009:adverse effects / Q000379:methods; D015992:Body Mass Index; D002968:Clavicle / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D006801:Humans; D016268:Internal Fixators; D004204:Joint Dislocations / Q000145:classification / Q000000981:diagnostic imaging* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000209:etiology; D011184:Postoperative Period; D057234:Preoperative Period; D011446:Prospective Studies; D011859:Radiography; D061665:Time-to-Treatment; D055815:Young Adult
keywords: Acromioclavicular joint disruption; Acute; Arthroscopic stabilisation; Rockwood types III-IV-V